CONTENTSEDITORIAL 4 Message from CEO Venkat Changavalli

EDITORIAL ARTICLE 5 The role of Leadership in Emergency Management Systems an EMRI perspective Venkat Changavalli

RESEARCH ARTICLES 7 Importance of Effective Emergency Medical Transport in Addressing Maternal Complications: Case Study, EMRI 108 EMS Service in Andhra PradeshDr. G. Francis Raj

Impact of EMRI services on Public Health Care System Delivery 17 Dr. Biranchi N. Jena

Contribution of EMRI’s 108 Services in Uplifting Life Expectancy in Andhra Pradesh 21Gopal Agrawal, Dr. Biranchi N. Jena

Medical Emergencies in Goa A Preliminary Analysis 25Dr. Saddichha Sahoo, Dr. Mukul K. Saxena

An Epidemiological Study of Emergencies resulting from snakebites in Andhra Pradesh 30Dr. Biranchi N. Jena, Dr. Nafeez S. Umar

REVIEW ARTICLESScorpion Sting 35Dr. H.S. Bawaskar, Dr. P.H.Bawaskar

Challenges in Emergency Management Research 47 Dr. Mukul K. Saxena

Events and News 50

Invitation for Submission of Manuscripts for 52Indian Emergency Journal (IEJ)

Editorial Board- Dr. G.V. Ramana Rao

- Dr. Anil Jampala

- Dr. Biranchi Jena

- Dr. Mukul Saxena

- Dr. Francis Raj

- Dr. Saddichha Sahoo

Greetings to you all!

We are happy to bring you the fourth issue of the Indian Emergency Journal. We have put together in this issue articles, news and more, to help you gain new insights into the emerging trends of emergency management, globally and within the country.

The year that passed has been one of dizzy growth. Today we are operating in eight states with more than 1400 ambulances, over 11,000 associates and growing every day towards the thirty million lives touched and one million lives saved mark, that we have set out to achieve by the year 2010.

The second batch of the post graduate programme for emergency management, in collaboration with the Stanford University has commenced its training. Research and analytics have provided critical insights

MESSAGE FROM CEO

to improve medical and process driven outcomes. The demographic, geographic and medical history has given us details that can be extrapolated to help step up the Emergency services in this part of the world.

The public private partnership has reached new heights with us partnering different state Governments across the country in a seamless manner.

Our role in supporting the Governments during the recent disasters – bomb blasts in Andhra Pradesh, Gujarat, Assam and the flood situation in Bihar have been opportunities for us to expand our horizons, to help save lives.I would like to take this opportunity to thank the Governments, Hospitals, Media and other partners, associates and Governing Board of EMRI for their outstanding support.

- Venkat Changavalli CEO - EMRI

3

MESSAGE FROM CEO

4 55

To quote Peter Drucker “Management is doing things right, leadership is doing the right things”. Leadership, as in any walk of life, is an integral and important part of vision, mission, growth, strategic direction, partnership, sustainability and motivation to all the stakeholders involved.

Of the six billion and more persons in the universe, only a third of them are covered by some form of EMS. This field deals with precious lives every day, including emotional and psychological issues of trauma, fire, near assault and life threatening medical situations. Passions and emotions can be high, while empathy

The role of Leadership in EMS systems – an EMRI perspective- Venkat Changavalli

and understanding may or may not be there (based on personal involvement). Lack of awareness, abject poverty, surprise, are elements that are there as a mix. This dynamic and evolving field requires visionary leadership – leadership par excellence, a person, or team who has the intimate understanding of human beings, processes, technology organizations and also thinks out- of- the- box.

Real motivation lasts longer than twenty four hours- the keys to effective leadership lies in detailing to the patient/ victim that you, can visualize the outcome. “Let our advance worrying become

EDITORIAL ARTICLE

55

Author: Venkat Changavalli CEO - Emergency Management and Research Institute, Secunderabad, India e-mail: Venkat_Changavalli@emri.in

advance thinking and planning”, said Winston Churchill. This is in line with Thinking, Doing, and Communicating (TDC) philosophy of EMRI.

The areas of focus for most EMS leaders are, planning; mission; vision; strategy information and analysis; human resources development; process management; stakeholder analysis; decision making; problem solving; research; relationships; partnerships and innovations.

Leadership involves working with individuals, team members with diverse strengths and weaknesses. The back bone of extended leadership with the team, allows for better chances of achieving the goal (mission/vision) of the organization. This is interdependent on the levels of communicating the good work; sharing progress with the group, acknowledging high performance, effort and commitment; fostering an environment of dignity and respect. Analysis of what has not been done right or to specification, leads to continuous quality improvement.

The mission and vision of the Emergency Management Systems are arrived at by the leadership, keeping the prevalent scenarios in mind. The vision of responding to 30 million emergencies and saving a million lives by 2010 is what EMRI has set out to accomplish. This vision needs to be achieved while being the best in class, sustainable and scalable and universally accessible in all states of India.

The mission of delivering the same rests with the leadership which needs to plan, implement, innovate, collaborate and provide the service in an accepted framework and is a major challenge for this constantly growing EMS system.

The strategy for implementation of the same is to plan adequately in a framework which benefited the various stakeholders. India is a country where availability, affordability and accessibility are a major challenge. Innovative ideas are a necessity to take forward this gigantic task. A toll free number providing free service to the end user is perceived as the need of the hour since many cannot afford even to make a call. The integrated emergency response approach to an emergency, where the call is taken and dispatch of an ambulance (and/or police/fire vehicle) happens from the same centre is yet another innovation. The design of the ambulance to provide immediate relief in any of the forty seven emergencies where the height of the ambulance, place for relatives, equipment for medical, police and fire emergencies were incorporated is yet another innovation.

Pre-hospital care is provided from the emergency response centre to the victim by virtual hand-holding either by a doctor or Emergency Medical Technician and in the ambulance, thus giving the golden hour an extension, before reaching the hospital. Innovative strategies are constantly being developed by EMRI to serve this large population.

Research, both retrospective and prospective, in the area of EMS is a unique aspect of the leadership strategy at EMRI. Emphasis is more on championing new ideas and salutations across this sector. Creating, evolving and emulating of good practices and spreading knowledge about them is also an active part of the leadership strategy.

Measures have been created around each activity of the organization. These measures are analyzed and are also used to predict the future state of healthcare and disease patterns. These allow for better deployment and utilization of resources, by reconfiguring processes where necessary. They help with documentation of processes, prevention of avoidable outcomes and support education and training.

The potential to provide cutting-edge, effective interventions in specific emergency conditions, integration with hospital care and plan for capacity and capabilities of medical intervention is viewed by the leadership.

Relationships and partnerships to take forward the growth of the institution is an area of priority for leaders. They are the voices of experience that strengthen the EMS system. Communicating experiences and sharing the same for better outcomes is the strength derived from strong relationships and partnerships. The Public Private Partnerships with governmental agencies, technology partnerships, protocols, knowledge transfer; a new cadre of professionals are amongst some of the relationships that EMRI has established and cherishes for the outcomes achieved using collaborative efforts.

The creation of work force and their sustained interest in the high pressure areas of EMS is one of the major challenges of leadership. Growing leaders that are responsible at several tiers and motivating them beyond the twenty four hours is part of the path of preparedness in an organization where rapid growth and change are the only constants. Great leadership will make an organization more effective, cost efficient and maintain better employee morale at all levels which are important components of any thriving organization such as EMRI.

6 77

Importance of Effective Emergency Medical Transport in Addressing Maternal Complications: Case Study, EMRI 108 EMS Service in Andhra Pradesh

Importance of Effective Emergency Medical Transport in Addressing Maternal Complications: Case Study, EMRI 108 EMS Service in Andhra Pradesh

Safe motherhood is a woman’s ability to have a safe and healthy pregnancy, delivery and post-delivery period. Complications associated with pregnancy and childbirth is the leading cause of death and disability among women of reproductive age in developing countries. Unlike other health emergencies which are typically unforeseen and unplanned events that require immediate attention, pregnancy and childbirth are natural processes and careful planning and early identification of complications can save lives of mother and new born infants. If treated appropriately and in a timely manner, almost all women who develop pregnancy-related complications can be saved from death and disability.

At a time when Emergency Medical Services (EMS) are significantly underdeveloped in India, compared to those in the developed world, the Emergency Management and Research Institute (EMRI) was established in Andhra Pradesh on the 2nd of April 2005. This is a unique Public-Private-Partnership (PPP) between the Government of Andhra Pradesh and the

EMRI foundation. EMRI through its brand, 108 provides complete pre-hospital emergency care from event occurrence to evacuation to a hospital.

The present study is based on all the reported emergencies associated with pregnancy from July 2007 to July 2008 in the state of Andhra Pradesh of India. Data collection is done using a pre-prepared PCR form filled by the emergency medical technician in the Ambulance.

Results: Of the total 1,21,454 cases handled by 108 Emergency Response Service, 60% of the cases were pregnant women with labour pains or some other health risk and nearly 39% of the cases had one or two complications along with labour pains which required medical intervention. The remaining one percent included cases which were critical in nature which required immediate medical intervention within a short time. By timely shifting of the cases to hospital and by providing quality pre-hospital care during transport in the Ambulance most of these lives have been saved

Dr. G. Francis Raj

LEADRESEARCH ARTICLE

Abstract:

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Introduction: Maternal mortality remains one of the most daunting public health problems in India and reduction in maternal mortality has been identified as a prominent component of the National Rural Health Programmes. More women die in India during childbirth than anywhere else in the world. Of the 5.36 lakh women who died during pregnancy or after childbirth in 2005 globally, India accounted for 1.17 lakh. India, along with 10 other countries, accounted for almost 65% of global maternal deaths in 2005. The maternal mortality ratio (MMR) in India is 450 deaths per 1,00,000 live births. Also, the probability that a girl will die from a complication related to pregnancy and childbirth during her lifetime is 1 in 70, in India.1 To this day, maternal mortality remains the most neglected issue in India with immense focus on family planning and population control programmes.

Having a child, the most basic of human joys, continues to be a life-threatening proposal for many women around the world. ‘‘NFHS-III found that women in India lack quality care during pregnancy and childbirth2. Almost one in four women (23%), who gave birth in the last eight years, received no antenatal care, ranging from 1% or less in Kerala and Tamil Nadu to 66% in Bihar. The quality of antenatal care also needs improvement in India. Only 65% of women receiving antenatal care received iron and folic acid supplements, and only 23% took the supplements for at least 90 days. Only 4% of expectant mothers took a de-worming drug during pregnancy. Failure to take an iron supplement and de-worming drugs increases the risk of anaemia, a major problem for mothers and children in India. Home births are still common in India. NFHS-III found that 37% of deliveries were assisted by a traditional birth attendant, and 16% were delivered by a relative or other untrained person.2

Evidence has shown that access to and utilization of high-quality emergency obstetric care (EmOC) and availability of quality emergency transport can significantly bring down the number of maternal deaths. This country of more than 1 billion people contributes approximately 20% to 24% of the world’s maternal deaths.3

Throughout history, pregnancy has carried a high risk of death, secondary to such complications as obstructed labor, ruptured uterus, postpartum hemorrhage, postpartum infection, hypertensive disease of pregnancy, and complications stemming from unsafe abortion.

This situation is particularly tragic because pregnancy is not a disease but a simple physiological process, which should not culminate in the death of women. No woman should die giving birth to a child

so much looked forward to. It doesn’t require new technologies or drugs to radically lessen maternal mortality. Rather, widespread access to antenatal care, emergency obstetric care (EmOC), and affordable and accessible quality emergency medical transport, which would lead to dramatic reductions in the unacceptably high maternal mortality ratios.

A woman faces the risk of death or disability every time she becomes pregnant due to pregnancy-related complications. However, if treated appropriately and in a timely manner, almost all women who develop pregnancy-related complications can be saved from death and disability. Not providing appropriate and adequate maternal care is a human rights violation.

High maternal death rates are not explained by poverty alone: political will and effective strategies can save the lives of mothers despite limited financial resources.4

Safe motherhood is a woman’s ability to have a safe and healthy pregnancy, delivery and post-delivery period. Complications associated with pregnancy and childbirth are the leading cause of death and disability among women of reproductive age in developing countries. According to the World Health Organization (WHO), a maternal death is the death of a woman while pregnant or within 42 days of the termination of her pregnancy from any cause related to or aggravated by the pregnancy or its management. The leading causes of maternal death are due to five direct causes: hemorrhage, sepsis, complications resulting from unsafe abortion, prolonged or obstructed labor and hypertensive disorders.5

Implications of Maternal Mortality• Worldwide, one woman dies from a pregnancy-related

complication every minute.6 Every day 1,440 women die from complications of pregnancy and childbirth.7

• Every year, approximately 5,29,000 women die from maternal causes.8

• Every year, 8 million babies are stillborn or die before they reach the age of one month.9

• For every woman who dies, approximately 20 more suffer from injuries, infection and disabilities in pregnancy and childbirth.10

• A million or more children are left motherless each year as a result of maternal mortality. These children are three to 10 times more likely to die within two years than children who live with both parents.11

Author: Dr. G. Francis Raj, Applied Research, Emergency Management and Research Institute, Hyderabad, India. e-mail: francisraj_g@emri.in

8 99

• One-quarter of women in developing countries, approximately 300 million women today, suffer problems in pregnancy and delivery.12

• UNICEF reports that more girls and women from developing countries die from childbirth complications than from any other cause. Of the 1,400 women and girls who die each day from delivery complications, 99 percent of them are in less developed countries.13

• Postpartum hemorrhage has resulted in at least 25 percent of the 5,00,000 maternal deaths globally. In some countries, this number reaches up to 60 percent.14

• A study of 49 countries found that access to reproductive health services is one of two key indicators for maternal mortality in developing countries.15

• The lifetime risk of maternal death is highest in sub-Saharan Africa, where a woman’s risk of dying from maternal causes is as high as 1 in 16, compared with 1 in 2,800 in industrialized countries. African women’s risk of dying in childbirth is 175 times greater than for women in developed regions.16

• UNICEF states that while sub-Saharan Africa has only 12 percent of the world’s population, the region has 42 percent of all deaths under age five.17

• Between 1995 and 2000, the world’s 1.3 billion women of child-bearing age experienced a total of more than 1.2 billion pregnancies. Of these, well over one quarter were unintended.18

• Where contraception is inaccessible or of poor quality, many women will seek to terminate unintended pregnancies. Estimates based on figures for the year 2000 from the World Health Organization indicate that 19 million unsafe abortions take place each year. That is, approximately one in ten pregnancies ends in an unsafe abortion. Almost all unsafe abortions take place in developing countries.19

• Worldwide, unsafe abortion is responsible for approximately 70,000 pregnancy-related deaths each year.20

• While unsafe abortion is completely preventable, it continues to be a major cause of maternal mortality and morbidity in the developing world. The World Health Organization reports that 1 in 270 unsafe abortions will lead to fatal complications, with all deaths occurring in developing countries. Nearly half of all deaths from unsafe abortion take place in sub-Saharan Africa, where unsafe abortion constitutes between 10 to 50 percent of all maternal deaths.21

Of immediate concern in safe motherhood are the immediate causes of

maternal mortality which all stem from the mother’s failure to receive

adequate medical management of major maternal complications:

toxemia or severe hypertensive disorders during pregnancy. This can

be prevented by adequate pre-natal care/referral for hospital-based

care. Obstructed birth is another serious cause, which can be rectified

by a hospital-based delivery through the cesarean section. Postpartum

hemorrhage or hemorrhage during pregnancy is the most serious

cause which needs hospital-based emergency obstetrical attention.

Finally death due to sepsis: post-partum or abortion related can be

avoided by a clean delivery and adequate post-partum care. Almost all

these complications need availability of quality and timely emergency

medical transport.

The Three Delays in Maternal Mortality: Maternal mortality in resource-poor nations has been attributed to

the “3 delays”: delay in deciding to seek care, delay in reaching care

in time, and delay in receiving adequate treatment.22, 23

The first delay is on the part of the mother, family, or community

not recognizing a life-threatening condition. Because most deaths

occur during labor or in the first 24 hours postpartum, recognizing

an emergency is not easy. It takes skill to predict or prevent bad

outcomes and medical knowledge to diagnose and immediately act

on complications. By the time the lay midwife or family realizes

there is a problem, it is too late.

The second delay is in reaching an appropriate health care facility

due to lack of affordable and accessible quality emergency transport

or may be due to road conditions. Many interior villages do not

have access to proper motorable roads and majority of the families

do not have access to any type of vehicles during emergencies. In

a country with minimal public transport facilities and insufficient

and expensive private transport, people have no other choice but

to depend on whatever is available. This means it may take many

hours or in some cases, days to reach an appropriate health care

facility. Women with life-threatening conditions often do not make

it to the facility in time.

The third delay occurs at the healthcare facility. Upon arrival,

women receive inadequate care or inefficient treatment or simply

referred to another appropriate hospital. Even after reaching

appropriate facility the many fragile health care facilities do not

have the technology or services necessary to provide critical care to

hemorrhaging, infected, or seizing patients. Omissions in treatment,

incorrect treatment, and a lack of supplies also contribute to

maternal mortality.

99

services more than any other districts with 7% and Hyderabad

utilized lowest service (1%) for pregnancy cases (Fig-1).

Figure 1:

The estimated number of live births in Andhra Pradesh in 2007 is

approximately 15,00,000 lakhs as per the statistics of Department

of Health and Family Welfare, Government of Andhra Pradesh.

Of these live births, 108 Emergency Services had handled 8.1% of

the overall pregnancies taking place in AP in 2007.

Regional Distribution of 108 EMS Services: Andhra

Pradesh consists of 23 districts including its State capital Hyderabad.

There are broadly three regions in Andhra Pradesh; Telangana,

Andhra and Rayalaseema.

Telangana Region: Of the 23 districts, 10 districts, which are

located on the North-West side of Andhra Pradesh bordering

Maharashtra, Chattisgarh and Karnataka States form Telangana

region. The Telangana region consists of Hyderabad, Adilabad,

Karimnagar, Warangal, Nizamabad, Medak, RangaReddy,

Nalgonda, Mahabubnagar and Khammam districts. Based on the

2001 Census, these districts together consist of nearly 41% of the

total population of Andhra Pradesh.

Andhra Region: The Andhra region consists of 9 coastal

districts which are located towards the eastern and north eastern

side of Andhra Pradesh bordering Orissa and Tamilnadu

States. Andhra region consists of Nellore, Prakasam, Guntur,

Krishna, West Godavari, East Godavari, Vishkapatnam,

Vizianagaram and Srikakulam districts. Based on the 2001 Census,

these districts together consist of nearly 41% of the total population

of Andhra Pradesh.

Unlike other health emergencies which are typically unforeseen

and unplanned events that require immediate attention, pregnancy

and childbirth are natural process and careful planning and early

identification of complications can save the mothers’ lives.

At a time when emergency medical services are significantly under

developed in India, when compared to those in the developed world

the Emergency Management and Research Institute (EMRI) was

established in Andhra Pradesh on the 2 nd of April 2005, as a unique

Public-Private-Partnership (PPP) between the Government of Andhra

Pradesh and the EMRI foundation to fill this gap in the state of

Andhra Pradesh. EMRI through its brand 108 Emergency Service

provides complete pre-hospital emergency care from event occurrence

to evacuation to an appropriate hospital.

Since its inception, EMRI has significantly impacted in dispatching

emergency personnel to the scene of emergency, conduct triage, provide

onsite treatment and transport patients to appropriate hospitals for

definitive treatment. Over the last three years since its establishment in

India, EMRI, through its flagship 108 Emergency Service has attended

to over one million emergencies and saved lives.

Methodology: In 2007 alone, with a fleet of 502 Ambulances in Andhra Pradesh

State and trained emergency medical technicians, EMRI has

provided emergency medical transport and pre-hospital care to

over 1,30,000 women in labour. The process of addition of another

150 Ambulances to the existing fleet in Andhra Pradesh began in

June 2008 and by end of August 2008, all 652 Ambulances were in

place. The present study is based on all the reported emergencies

associated with pregnancy from July 2007 to July 2008 in Andhra

Pradesh. Data collection was done using a pre-prepared Pre-

Hospital Care Record (PCR) by the emergency medical technician

in the Ambulance. After thorough verification of data only

1,21,454 eligible cases were selected for the study. Three types of

records were used for the studies which are collected by EMRI.

They are emergency response records, which are maintained by the

emergency response officer, pre-hospital care records which are

written by the emergency medical technician in the Ambulance and

48-hour follow-up records.

Results: Regarding the utilization of 108 Emergency Services the data

shows that utilization of 108 Emergency Services for pregnancy

related emergencies is not evenly spread throughout the State. As

per the data, pregnant women and their families in Ananthapur

and Mahabubnagar districts have utilized the 108 Emergency

WG5%

Srkm 6%

Vsknm4%

Vznm5% Wrgl

3%

Adb4%

Antp7%

Chtr6%

Nlor6%

Kdp6%Krmr

2%Khm3%

Krsn4%

Krnl5%

Mbnr7%

Gntr 5%

Nzbd4%

Prksm 6%RR 2%

Mdk 2%

Nlgd 3%

Hyd 1%

EG 4%

Distribution of Pregnancy Cases Handled by108 EMS Service from July 2007 to July 2008

10 1111

Rayalaseema region: The Rayalaseema region consists of

4 districts which are located towards the South-Western side

of Andhra Pradesh bordering Karnataka State. Rayalaseema

region consists of Ananthapur, Chittoor, Kadapa and

Kurnool districts. Based on the 2001 Census, these districts

together consist of nearly 18% of the total population of

Andhra Pradesh.

Ambulance Deployment: There were 502 Ambulances in

service in Andhra Pradesh from July 2007 to June 2008. Another

150 Ambulances were added to the existing fleet from June 2008

onwards which, was completed by August 2008. Of the 502

Ambulances which were in service, 43% of the Ambulances

were deployed in Telangana region, 38% were deployed in

Andhra region and 19% were deployed in Rayalaseema region.

Data suggests that even though the percentage of Ambulance

deployment in Telangana region is more based on population

distribution of the State (Census 2001, Telangana region 41%,

Andhra 41% and Rayalaseema 18%), the utilization of 108

Emergency service remains less compared to other regions. On

the other hand in Andhra region even though the deployment

of Ambulances is marginally less, the utilization of 108 EMS

Services is quite high (Table-1).

Age distribution: All pregnant women between the reproductive age group of 15 to 45

years were selected for the study. Of them majority of the pregnant

women (60%) belonged to 20 to 24 age group and a quarter (25%)

belonged to 25 to 29 age group. About 9% of women belonging to 15

to 19 age group were pregnant with slight improvement compared to

17.7% which was reported in NFHS II in 1998-99. This indicates that

fewer women below the age of 19 years are getting pregnant and giving

birth to children below the age of 19 years. The mean age of all the

pregnant women was 23.1 years.(Fig-2)

Figure 2:

Geographic Distribution of Pregnancy Cases The distribution of pregnancy cases across the State shows that 108 EMS service is used mostly (93.2%) by women living across

the rural areas and women living in tribal areas which is 2.5% of the

overall cases handled by 108 EMS service. Few women in urban areas

(4.3%) have accessed 108 EMS service for transport of pregnancy-

related emergencies. Since other sources of transport are available

and accessible to women in urban areas, it is possible they may be

utilizing them. (Table : 2 )

The results clearly indicate that 108 EMS service has been successful

in gaining the trust of the people by providing accessible and quality

EMS service free of cost. This also fulfills the NRHM goal of

making the health services accessible to people living in rural and

interior areas of India.

Social Status of Pregnant Women: Table-3 shows social status of pregnant women utilized 108 services.

Of the total women served by 108 services, social status information

is available for 1,18,259 of them. Majority of the (45.8%) pregnant

women were from backward communities, and 28.2 % from scheduled

communities and 13.1 % of pregnant women belonged to scheduled

tribe and 12.9 % belonged to other communities respectively in the

State (Table-3). According to the 2001 Census of India, Andhra Pradesh

Age Distribution of Pregnancy Cases

20-2472491(60%)

35-391500 (1%)

40-45957 (1%)

25-2930866 (25%)

30-345133 (4%)

15-1910507 (9%)

Table 1: Regional Distribution of 108 EMS Services

Region Population %(Census 2001)

108 services assessed by

Pregnant women (%)

Telangana(10 Districts) 41% 31%

Andhra(9 Districts) 41% 45%

Rayalaseema(4 Districts) 18% 24%

Table 2: Geographic Distribution of Pregnancy Cases

Area Frequency Percent

Rural 113144 93.2

Tribal 3025 2.5

Urban 5260 4.3

Total 121454 100

1111

had SC and ST population together 27%. The EMRI data shows that

41% of women from SC and ST communities had accessed 108 EMS

services. This establishes the fact that 108 Emergency Services have

been able to make inroads into the rural and tribal areas and has been

successful in building the trust of women and their families in SC and

ST communities to use 108 Emergency Services during pregnancy

related emergencies.

Rural, Urban and Tribal Classification of Pregnant women based on Social Status: Table-3 shows social status of Rural, Urban and Tribal classification

of pregnant women utilized 108 services.Among rural population

46.4% of pregnant women from backward communities, 12.9% of

women from other communities, 28.6% of women from Scheduled

Castes and 12.1% of women from Scheduled Tribes. Where as

in Tribal area majority of pregnant women (56.4%) belongs to

Scheduled Tribes, followed by 22.4% of women form backward

communities followed by 15.4 % women from Scheduled Castes.

Only 5.9% of pregnant women belongs to other communities in

tribal areas of Andhra Pradesh.

Economic Background of Women: Of the total that have accessed 108 EMS Services, majority of the

women were housewives (59%). Nearly 6 out of 10 pregnant women

were housewives, 4 out of 10 women were daily wage labourers

(38%). Few women were self employed (1%) or employees (1%)

or were students (1%). The study findings further reiterate the

confidence and trust that 108 EMS service has built especially

among pregnant women from poor economic backgrounds in rural

areas.

Cause of Emergency: Majority of the women who were shifted to hospital were having

labour pains (60%). The rest 40% of the women had some

complication during pregnancy or childbirth. 10% of pregnant

women were suffering from Hemorrhage, either during pregnancy

or childbirth or during postpartum period, which is the single most

cause of maternal death world over. 8% of pregnant women were

suffering from abortionrelated complications and 9% of women

had medical conditions complicating pregnancy. The rest 4% of

women were suffering from breech presentation and 3% each were

suffering from bleeding or other causes of undergoing Caesarean,

3% due to fetal loss and another 3% due to convulsions and

eclampsia during pregnancy. (Fig-3)

Figure 3:

Women’s Health Status during Transport in 108 Ambulance:Of the total 1,21,454 women who were shifted to hospital for

pregnancy-related reasons, data was available for 55,645 cases

for all variables. The study results show that 5 out of 10 women

who were shifted to hospital (51%) were stable and their health

remained statuesque during transport and nearly other 5 out

of 10 women’s health condition improved during transport.

The health condition of only a few pregnant women (218)

worsened during transport and fewer women (17) died before

the arrival of Ambulance or during transport in the Ambulance.

(Table-4)e 5:

Pregnant Women’s Health Status after 48-hours Follow-up: EMRI follows a standard 48-hour and 120 follow-up of cases handled by 108 Emergency Services. The data then collected is filled in PCR report. The study results (Table- 5) show that majority of the women shifted to hospital (66.2%) were all right and discharged

Table 3: Social Status of Pregnant women with Urban, Rural and Tribal Classification

Area BC OC SC ST Total

Rural 46.4 12.9 28.6 12.1 100

Tribal 22.4 5.9 15.4 56.4 100

Urban 45.8 17.2 28.1 8.9 100

Total 45.8 12.9 28.2 13.1 100

Cause of Emergency Details

Abortions

Abnormal Presentations

Bleeding in Pregnancy

(Before or After Delivery)

Eclampsia Convulsionsin Pregnancy

Foetal loss

Medical conditionscomplicating pregnancy

Post Caesarian in labor

Precious Pregnancy60%

3% 9%3%

3%

10%

4%

8%

Table 4: Victim’s Health Status during Transport

Health Status Cases Percentage

Improved 34,042 49.15

Status quo 34,990 50.51

Worsened 218 0.31

Died 17 0.02

12 1313

from hospital and 32.3% of women were stable and out of danger, but still in hospital. The health condition of the remaining 1% of women (559) was still critical and another 163 women were sent away by the hospital or by the emergency medical technician of the Ambulance after giving first aid. But 56 women had died maternal death after shifting to a health facility at the time of 48-hours follow up. (Table-5).

Incident Location Details: Figure-4 shows incident location of pregnancy cases shifted to health facility by 108 services.

Figure 4:

Of the 1,21,454 women who were pregnant, majority of the pregnant women (84%) were shifted to health facility from their residence. The other women who were shifted to hospital were picked up either from road side (6%), highway (1%), other places (4%) and a few were also shifted from their workplaces. But nearly 4% of the women have used 108 EMS Services for inter-facility transport or referral. (Fig -4)

Place of Occurrence of Maternal Death: The combination of emergency response centre data, Pre-hospital Care Records filled by emergency medical technicians in the Ambulance and 48 hours follow-up conducted records show that of the total 1,21,454 pregnancy cases handled by EMRI 108 EMS

services, there were 73 maternal deaths, 57 women died at home, 7 women died in hospital, 3 died on the road side, one died on the highway, 2 died in a public place and 3 others died in other locations (Fig-5).

Figure 5:

Age Details of Women who Died Maternal Death: Of the 73 pregnancies that culminated in maternal deaths, 8 women were 15 to 19 years age group, 39 were 20 to 24 years age group, 17 were 25 to 29 years age group, 5 were 30 to 34 years age group and 2 belonged to 35 to 39 years age group and 2 other women were 40 and above age group. (Table: 6)

Occupation Details of Victims of Maternal Deaths: Majority of the women were housewives (52.1%) and daily wage workers were 34.2%. The others include employee 2% and self employed 2.7%. (Table-7)

Table 5: Victim’s Health Status after 48 Hours of Hospitalization

Health Status Cases Percentage

All right and discharged form hospital 36867 66.25

Stable, out of danger but still in hospital 18000 32.35

Condition is critical 559 1.00

First Aid 163 0.29

Died 56 0.1

Place of Maternal Death during pregnancy

Residence, 57

Public-Place, 2

Hospital, 7

High Way, 1

Others, 3Road Side, 3

Table 7: Occupation of Pregnant Women who Died

Type of Work Frequency Percentage

Daily wage work 25 34.2

Employee 2 2.7

House Wife 38 52.1

Self Employed 2 2.7

Not Specified 6 8.2

Total 73 100.0

Table 6: Age of Pregnant Women at the Time of Death

Age Frequency Percentage

15 - 19 years 8 11.020 - 24 years 39 53.4

25 - 29 years 17 23.3

30 - 34 years 5 6.8

35 - 39 years 2 2.7

40 and above 2 2.7

Total 73 100.0

Incident Location of Pregnancy Cases

4-Residence 100913 (84%)

3-PublicPlace1455 (1%)

2-Hospital 5288 (4%)

1-HighWay719 (1%)

7-Others 5037 (4%)

6-Work Place 228 (0%)5-Road Side

7795 (6%)

1313

Social Status of Women who Died Maternal Death: Most of the women who died belonged to the lowest strata of

income and low social status in the society (Table-8). 27 women

from SC community and 14 women from ST community either

died due to complicating pregnancy or while giving birth. The

number of women dying from SC and ST community is very high

when compared with the percentage of SC and ST population to

the total population. The other women who died include 25 women

from other backward communities and 7 women from other

communities. (Table 8)

Victims status at the time of 48-hour follow-up: At the time of 48-hour follow-up 56 women were already expired and

as per the emergency response center records 5 women have already

died during the interval between the call made to 108 Ambulance

service and arrival of Ambulance at the incident location. The nature

of the death clearly shows that victim or their family members either

could not judge the risk or identify the complications or neglected the

signs and symptoms and called Ambulance at the last moment. But

the study results show that there were 8 postnatal deaths of women

who were discharged from the hospital on the ground that they were

alright but they died after reaching home due to complications and

another 3 women whose condition was considered stable and out of

danger also succumbed to death. (Table-9)

Comparison of time taken to reach hospital and health outcome:The results of the study show that of the total 1,21,454 cases

handled by 108 service, only 73 maternal deaths were recorded.

Of the 73 maternal deaths, 5 women have already died before the

Ambulance reached incident location as per emergency response

center records (Table-10). In effect the maternal deaths taken place

after case taken up by 108 Ambulance are only 67 deaths. Another

32 deaths have taken place at home or in the hospital based on

the 48 hour follow-up. These deaths came into light when patient

follow-up was conducted at 48 hours. In this case Ambulance may

or may not be assigned. In another case 6 women died even when

the Ambulance took less than 30 minutes to shift the victim to an

appropriate hospital. Thirteen women died when the Ambulance

took 30 to 45 minutes to reach the health facility and 10 women

died between 45 minutes to one hour. More women (12) died when

the Ambulance took more than an hour to shift the patient to the

health facility.

Table 10: Comparison of Total Time taken to reach Hospital and Maternal Deaths

Average Time Taken

Died during transport or at home as per

Emergency response records

Died at home or in hospital as per 48 hour

follow-up recordsTotal

Died at home during the interval between call made to 108 and arrival of Ambulance or after discharge from hospital

5 27 32

Less than 30 minutes 3 3 6

31 to 45 minutes 4 9 13

46 to 60 minutes 3 7 10

61 and above 2 10 12

Table 8: Social Status of Pregnant Women who Died

Caste Frequency Percent

BC 25 34.2

OC 7 9.6

SC 27 37.0

ST 14 19.2

Total 73 100.0

Table 9: Status of victim at the time of 48-hour follow-up

Health Status Frequency

All right and discharged from the hospital 9

Expired 56

Died at home during the interval between call made to 108 service and arrival of Ambulance 5

Stable, out of danger, but still in hospital 3

Total 73

14 1515

Discussion: EMRI has been able to instill confidence and trust among people

especially in rural areas to use 108 Ambulance services during

medical emergencies. More number of women and their families

from rural areas are using the service. Significant number of women

from scheduled castes and scheduled tribes are using the service. It

is a welcome sign and for the first time in India, the data shows

that 108 Services have been used by poorest of the poor sections

of the society. Perhaps the deaths of the women who died could

have been saved if only they were able to recognize the danger signs

during pregnancy. Most of the deaths have taken place at home

or on the way to hospital since women could not identify the risk

factors, no trained personnel were there to identify high risk cases

for timely referral.

Of the total 1,21,454 cases handled by 108 Ambulance service 60%

of the cases were pregnant women with labour pains or some other

health risk and nearly 39% of the cases had one or two complications

along with labour pains which required medical intervention. The

rest one percent included cases which were critical in nature which

required immediate medical intervention within a short time. By

timely shifting of the cases to hospital and by providing excellent

pre-hospital care in the Ambulance most of these lives have been

saved. The maternal deaths were only 73 for the total 1,21,454 cases

studied. Of these cases, the 48 hour follow up of the victims was

conducted in only 46% of the cases.

As per the government of Andhra Pradesh, Department of Health

and Family Welfare, the maternal mortality ratio per one lakh live

births is 197 in 2007. Most of the maternal deaths (60%) take place

in developing world during postpartum period, with 24% during

prenatal period and another 16% during labour and childbirth.

Most post-partum deaths occur largely within few days following

childbirths. Forty five percent occur within 24 hours and 68% occur

within the week immediately following delivery. Of these deaths

haemmorrhage accounts for 50% of all post-partum deaths and

over 90% of deaths due to haemmorrhage happen during the

seven days after delivery, within an average interval of only 12

hours from onset of haemmorrhage to death. Mortality due to

eclampsia, which is responsible for 13% of post-partum deaths, is

concentrated in the immediate Post-partum period, with an average

span of two days following onset. Infection is responsible for

30% of post-partum deaths and a fifth of these deaths take place

during first week of post-partum period. Approximately 15% of all

pregnancies yield a life threatening complication as per this study.

According to UNICEF estimates, as much as 40% of pregnancies

manifest some form of complication.24 Studies have shown that

maternal deaths can be drastically reduced by providing affordable

and quality emergency medical transport with pre-hospital care. In

a study conducted in Mpumalanga, lack of emergency transport

between health institutions was identified as a major factor in at

least 38% of maternal mortalities. Delays in transporting women

from one health facility to another were reported as a factor in 14%

of all maternal mortalities countrywide. But this figure is probably

much larger, as it does not include delays in transporting women

from their homes to health institutions.25

The study of 1,21,454 cases for which pregnancy related emergency

pre-hospital care is provided by 108 Ambulance service shows that

there were a total of 73 maternal deaths. The results of total deaths

divided by one lakh live births shows nearly 60 maternal deaths per

lakh live births. In the study 8% of the women underwent abortion

and 48-hour follow-up of the pregnant women was conducted for

only 46% of the pregnancy cases. Going by the fact that; most number

of maternal deaths take place within 48 hours and one week of post-

partum and nearly 38% of maternal deaths can be averted by providing

quality inter-facility emergency transport and availability of quality

emergency transport for shifting pregnancy cases from home will

further drastically bring down the maternal mortality reduce delivery,

one can safely say that with the effective intervention of EMRI 108

Ambulance service, the maternal mortality ratio for the 1,21,454 cases

handled by EMRI has been brought down to less than 50% of the

existing maternal mortality ratio in Andhra Pradesh.

If we go by the official figures of maternal mortality ratio of

government of Andhra Pradesh it is 197 per one lakh live births.

But results of several other studies have indicated that MMR in

AP could be much higher than what the government of Andhra

Pradesh claims. In a study conducted by Institute of Health

Systems (IHS) for three districts in AP, the study results showed

maternal mortality ratio to be as high as 900 for one lakh live births

in one district of AP.26 In a similar study conducted by Academy

for Nursing Studies and Women’s Empowerment Research Studies

(ANSWERS) using Sisterhood Method in Bidar and Medak

districts have shown maternal mortality ratio to be 341 in Medak

district of AP.27 As per the SRS (2003) MMR in AP is 195.28 In

spite of the differences that exist in maternal mortality ratio for AP

with few studies being conducted on this important area, one can

safely claim that EMRI through its flagship 108 Emergency Medical

Services has contributed to the development of reproductive health

of women in AP by significantly bringing down the maternal deaths

in Andhra Pradesh.

1515

References

1. WHO/UNICEF/UNFPA press release, 12 October 2007, ‘Maternal Mortality Declining in Middle-income Countries; Women Still Die in Pregnancy and Childbirth in Low-income Countries’.

2. NFHS-3. National Family Health Survey, Ministry of Health, Medical and Family Welfare, Government of India, 2005-06.

3. Save the Children. State of the World’s Mothers 2006: Saving the Lives of Mothers and Newborns, 2006.

4. Dileep V, Mavalankar, Rosenfield A. Maternal Mortality in Resource-Poor Settings: Policy Barriers to Care. American Journal of Public Health. 2005 February; 95 (2): 200-203.

5. White Ribbon Alliance for Safe Motherhood/India, Saving Mothers’ Lives, What Works, 2002.

6. Maine D, Akalin M, Ward V, Kamara A. The design and evaluation of maternal mortality programs. Columbia University, NY7 Center for Population and Family Health, School of Public Health; 1997.

7. UNFPA. Reproductive Health for Communities in Crisis: UNFPA Emergency Response, 2001.

8. WHO, UNICEF, and UNFPA. Maternal Mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA, 2000.

9. UNFPA. Reproductive Health in Refugee Situations: An Inter-agency Field Manual, Geneva, 1999.

10. UNFPA, Fast Facts on Maternal Mortality and Morbidity. [Accessed September 1, 2006]

11. UNFPA, Fast Facts on Maternal Mortality fand Morbidity. (Accessed September 1, 2006)

12. WHO/UNFPA/UNICEF/World Bank. Reduction of Maternal Mortality, Geneva, 1999.

13. UNFPA. Reproductive Health Fact Sheet, 2005.

14. McConville B. Preventing Postpartum Hemorrhage, LIVES: The Newsletter of the Partnership for Maternal, Newborn & Child Health, Issue 2, January 2006.

15. UNFPA. The State of the World Population 2005, New York, 2005.

16. UNFPA. The State of the World Population 2005, New York, 2005

17. McDougall L. Integration Achieves 20% Drop in Child Deaths, LIVES: The Newsletter of the Partnership for Maternal, Newborn & Child Health, Issue 2, January 2006.

18. Daulaire N, Leidl P, Mackin MA, Murphy C, Stark L. Promises to Keep: The Toll of Unintended Pregnancies on Women’s Lives in the Developing World, Washington, D.C., Global Health Council, 2002.

19. WHO. Unsafe Abortions, Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000. 4th Edition, Geneva, 2004.

20. Cohen S. Towards Making Abortion ‘Rare’: The Shifting Battleground over the Means to an End, Guttmacher Policy Review, Vol. 9, Number 1, Winter 2006.

21. WHO. Unsafe Abortions, Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated mortality in 2000 4th Edition, Geneva, 2004.

22. Weil L, Javet JC, Rebold A; Donnay F. Maternal Mortality Update 2002: A Focus on Emergency Obstetric Care. New York: UNFPA; 2003 [Accessed July 7, 2008].

23. Loudon I. Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800–1950. Oxford, England: Clarendon Press; 1992.

24. Middleberg MI. Promoting Reproductive Security in Developing Countries Published by Springer, 2003. Page – 31.

25. Stein. Jo. Health system failures result in maternal deaths [Online] [08.12.1999] URL:(http://www.health-e.org.za/news/article.php?uid=19991204)

26. District Family Health Survey (DFHS), a pilot study of three districts of Andhra Pradesh to estimate IMR, Fertility and MMR, Conducted by: Institute of Health Systems, Sponsored by Commissioner of Family Welfare, Government of Andhra Pradesh, 2000.

27. Unpublished study conducted by Academy for Nursing Studies and Women’s Empowerment Research Studies, Hyderabad, India, 2003.

28 Sample Registration System (SRS), 2003, Registrar General of India, New Delhi, India.

16 1717

Impact of EMRI Services on the Public Healthcare System Delivery

The health outcome of a country is dependent largely on the efficient functioning of public healthcare system apart from the quality of care. Overall healthcare system is a value chain comprising three major components viz. prehospital care, definite healthcare (hospital care) and rehabilitation. Each component is important in order to provide a secure and strong healthcare environment. In most developing countries the pre-hospitalcare, especially in case of emergency is the weakest link in the value chain and needs huge investment to make the public healthcare system more robust, so to ensure better health outcomes. Since Emergency Management and Research Institute (EMRI) provides the emergency

Dr. Biranchi N. Jena

ORIGINAL RESEARCH ARTICLE

Abstract:

response services along with quality pre-hospital care, the study examined the role of EMRI as an effective and efficient Emergency Management Services in improvement of the public healthcare system delivery. The study found that EMRI has enabled the overall health system to increase the healthcare facility utilization in Andhra Pradesh by ensuring the access to efficient and effective prehospital transport with adequate care.

Keywords: Health Care System, Maternal Mortality Ratio (MMR), EMRI

1717

Introduction: India has relatively poor health outcomes, despite having a well-developed administrative system, good technical skills in many fields, and an extensive network of public health institutions for research, training, and diagnostics. This suggests that the health system may be mis-directing its efforts, or alternatively be poorly designed.1 If statistics on the burden of diseases are observed, the deaths and DALYs (Disability Adjusted Life Years) arising out of chronic disease and injuries are increasing significantly in developing countries like India. Again deaths from suicides, snake bites, animal bites, drownings, accidents etc are increasing rapidly. Such a change in the burden of disease and DALY pattern strongly imply that an effective and efficient Emergency Medical Service (EMS) system needs to be an integral part of the public Health Care system. A quality EMS system would therefore be an effective feedback system to the definite care units for better management of the changing pattern of disease burden.

Emergency Medical Systems address a diverse set of diseases that span the spectrum of communicable infections, non-communicable conditions, obstetrics, and injuries. All of these conditions may present to the EMS in their acute stages (for example, diabetic hypoglycemia, septicemia, premature labor, or asthma), or be acute in their natural presentation (for example, myocardial infarction, acute hemorrhage, or injuries).2

A number of misconceptions about emergency care are often used as a rationale for giving it a low priority in the health sector, especially in low-income countries. These ideas include equating emergency care with ambulance transportation, neglecting the role of the community and facility care provided, and assuming that emergency departments and physicians are the only acute care resources.2 Such a narrow view ignores the important contributions by quick response through technology supported environments, state-of-art ambulances with enabling instruments and skilled manpower with adequate training to handle the onsite medical emergency. Therefore it is important to study the role of EMRI as an effective and efficient Emergency Management Services in improvement of the public health care system delivery.

Method:A comprehensive review of literature was carried out on the public healthcare system and its correlates. Subsequently, community level data and AP EMRI data on reported emergencies were used as comparators in the current study.

Results & Discussion:Reported literature and experiences in many countries indicate that an integrated health system is dependent on a solid base of primary care services in order to be clinically and fiscally successful. These

Author: Dr. Biranchi N. Jena, Senior Partner- Research, Emergency Management & Research Institute, Hyderabad. e-mail: biranchi_jena@emri.in

primary care services include expanded health maintenance activities and treatment at the primary care level, as well as coordination of access to specialty services as required. In the case of medical emergency, prehospital care is the primary care and the outcome results are highly dependent on the quality of prehospital care.

To me, the overall healthcare system is a value chain comprising three major components viz. pre-hospital care, definite healthcare (hospital care) and rehabilitation. Each component is important in order to provide a secure and strong health care environment.

However in most of the developing countries including India, pre-hospital care is the weakest link in the value chain and many health professionals are of the view that huge investment in this component would not procure the desired results in the healthcare system. In this context, it is true that pre-hospital care is often misunderstood by taking into account only the ambulance. However, the integrated part of pre-hospital care in the emergency like sensing the emergency and making the ambulance reach the victim within a specified time are among the most important and requires high levels of operational excellence. Pre-hospital care in a case of emergency is therefore effective and efficient if supported by better understanding the emergency (sense) and quicker response (reach). EMRI has been successful in proving that pre-hospital care is critical not only in terms of quality of intervention in the ambulance but also in ensuring better sensing and quick reaching through high end technology like GIS, AVLT to name a few. Pre-hospital care in an Emergency Medical Service system (ambulance service) consists of a “communication mechanism to initiate a response, a vehicle with a personnel to provide treatment and transport and a receiving facility to take the patient to”.3

After three years of operation in Andhra Pradesh, EMRI has given a big thrust to the pre-hospital care and there is a sea change in the community perception regarding pre-hospital care. In the process, it seems that pre-hospital care is becoming the strongest link in the value chain of healthcare system. Because of quality medical intervention in pre-hospital care, the victims’ expectation from the community healthcare system has gone up significantly. The health system especially in the rural set up like Primary Health Centres (PHCs) and Community Health Centres (CHCs) are now geared up to provide better healthcare to the community. Thus, EMRI has enabled the community to generate the demand for healthcare which would further help the state to efficiently equate the demand and supply of health care needs at a community level.

A study by Transportation Research Board (TRB), US finds that millions of Americans are considered to be “transportation disadvantaged” and dependency rate for accessing healthcare is quite high. Therefore lacking the access to the healthcare system

18 1919

during a critical condition though not a life-threatening situation due to lack of affordable transportation may lead to a need for emergency care and preventable hospitalizations. Access to non-emergency medical transportation (NEMT) can reduce emergency room and hospital expenditures for members of the transportation-disadvantaged population.4

MMR Institutional Delivery Births assisted by trained personnel

Total Urban Rural Total Urban Rural

INDIA 301 40.7% 69.4% 31.1% 48.3% 75.2% 39.1%

Andhra Pradesh 195 68.6% 85.0% 60.5% 74.2% 89.1% 66.9%

Source: MMR; SRS 2003, Institutional Delivery & Births assisted by trained personnel; NFHS-3, 2005-06

Table 1: Maternal Mortality Rate (MMR), Institutional deliveries and Births attended by trained personnel in India and Andhra Pradesh

Source: AP EMRI.

If we look at the statistics for Maternal Mortality Ratio (MMR) in India, SRS 2003 indicates that it is still high at 301 per 1lakh live births. A study by EMRI has revealed that there is a high association between institutional delivery and MMR and the study also shows that 80% variation in the MMR is due to the institutional delivery. (Table 1)

Studies also show that MMR is highly influenced by births attended by the trained personnel. NFHS 3 data reveals that there is substantial variation in urban and rural areas in both the indicators. This indicates that there is still lack of accessibility to the medical care units especially in the rural areas for which the non-availability of transport facility may be one of the leading causes. In Andhra Pradesh, institutional delivery in rural areas is only 60.5% where as the births attended by the trained personnel is 66.9%. This shows that there is an unmet need for the rural resident to access health care systems. The case for India is more critical in this respect as the existing health system fails in uplifting the institutional deliveries to reduce the MMR.

EMRI’s contribution in increasing institutional delivery and births assisted by trained personnel has been significant, as currently it is providing service to 20% of the total live births taking place in the state of Andhra Pradesh. The total proportion of pregnancy cases reported to EMRI has increased to around 20% in 2008 as compared to only 2% in 2006.

It has been noticed that EMRI provides more support to the rural health system by handling more pregnancy-related emergency cases in rural areas than urban. The graph (Fig-1) indicates that from 2nd quarter of 2007 there is a spurt in the total pregnancy cases handled by EMRI and from this period EMRI started its operation in rural Andhra Pradesh.

Considering high association between MMR and the institutional delivery, EMRI has enabled the public healthcare system to reduce the MMR by approximately 18% in Andhra Pradesh. If the same estimation has to be done for India, EMRI be would able to contribute around 23% to 38% in reduction of the MMR once its operation expands to the whole of India.

The rural primary health centers are woefully underutilized because they fail to provide their clients with the desired amount of attention and medication and because they have inconvenient locations and long waiting times.5 EMRI has enabled the overall health system to increase the healthcare facility utilization in Andhra Pradesh by ensuring access to efficient and effective prehospital transport with adequate care. In the process, healthcare facilities are receiving the victims in less critical conditions because of the effective pre- hospital care and the victim reaches the care unit with all the vitals measured by the trained medical technicians in the EMRI life saving ambulances. This process reduces the unnecessary delay at the healthcare unit and the treatment gets optimized. Thus EMRI enables the healthcare system to increase the probability of survival drastically in case of medical emergency which was completely

Table 2: Total Number of Pregnancy cases handled by EMRI

YearTotal Number of Pregnancy cases

handled by EMRI

% share of total Emergencies

handled

2006 2528 2%

2007 65009 17%

2008 (estimated)

293095 20%

1919

missing before the advent of EMRI intervention. The death rate out of the total medical emergencies has been reduced which in turn helps in uplifting the life expectancy rate. A study by EMRI has estimated the life expectancy in Andhra Pradesh has increased by 0.36 months, 1.8 months and 4.44 months respectively in 2005, 2006 and 2007 because of EMRI interventions in the state of Andhra Pradesh.6

Reducing the impact of emergencies on health has been identified as one of the essential public health functions (EPHF) in India.1 Emergency preparedness management, development of standards and guidelines for emergency management, coordination and partnership with other agencies and institutions, technical assistance at sub-national level to support the emergency preparedness are the four major criteria under which the factor “Reducing the impact of emergencies on health” as a EPHF has been evaluated. Though the overall scoring for “Reducing the impact of emergencies on health” is estimated to be 0.65 in the scale of 0 to 1, the individual scoring for the sub-components like coordination and partnership with other agencies and institutions, technical assistance at sub-national level to support the emergency preparedness has been rated poorly at 0.48 and 0.57 respectively.1 EMRI has proved to be an effective partner with the existing healthcare system and with well planned training and high-end technology, EMRI has mitigated the gap of technical support in emergency preparedness.

Conclusion:It has been evident that EMRI has enabled the overall health system to increase the healthcare facility utilization in Andhra Pradesh by

ensuring the access to efficient and effective prehospital transport with adequate care. Due to EMRI intervention, the whole health system in the country is getting strengthened and able to provide health care with more probability of success in terms of life saved. As a result of this the macro health indicators like MMR has been declined by 18% and the life expectancy has gone up by 0.36 months, 1.8 months and 4.44 months respectively in 2005, 2006 and 2007.

References:

1. India’s Public Health System How well does it function at the national level? World Bank Policy Research Working Paper 3447, November 2004

2. Olive C. Kobusingye et al. Emergency Medical Services, Disease control priorities in Developing countries, 2nd Edition, 2006

3. Roush WR. Principles of EMS Systems; Ch-2: Emergency Medical Service Systems

4. P. Hughes-Cromwick et al., Cost Benefit Analysis of Providing Non-Emergency Medical Transportation, Transportation Research Board, October, 2005

5. Duggal. R, Health Care Utilisation in India, Health Millions, 1994 Feb;2(1):10-2.

6. Jena B.N, Agrawal G., Contribution of EMRI in increasing the Life expectancy (A study by using the abridged Life Table, SRS), Unpublished project initiated by EMRI

20 2121

Contribution of EMRI’s 108 Services in Uplifting Life Expectancy in Andhra Pradesh

With the ongoing rapid transition in health, a dual burden of communicable and non-communicable diseases is escalating in India. To deal with the new emerging era of public health, it becomes essential for Emergency Medical Service System to be an inevitable part of National Health Care Service System. In 2005, Emergency Management and Research Institute (EMRI) started working in Andhra Pradesh with the vision of responding to 30 million emergencies per annum in PPP framework as a nodal agency and to save one

Gopal AgrawalDr. Biranchi N. Jena

ORIGINAL RESEARCH ARTICLE

Abstract:

million lives per annum. The study examined the contribution of EMRI’s ‘108’ services in uplifting life expectancy in Andhra Pradesh by utilizing life-saved data at EMRI. Single Decrement Life Table method has used for this. Study found a significant impact of EMRI’s ‘108’ services to the rise in life expectancy at birth during 2005-07.

Keywords: Emergency health, life expectancy, EMRI and ‘108’.

2121

IntroductionEmergency Medical Service (EMS) is essential part of any National Health Service System. While India is fighting to strengthen its health care delivery system, pre-hospital care (especially ambulance services) is the most neglected part of India’s health service system. There was a need for a process of rectifying the situation by launching an integrated ambulance service all over India.

In 2005, Emergency Management and Research Institute (EMRI) started functioning to provide integrated emergency services including Emergency Medical Services (EMS) across Andhra Pradesh. Operating in Public Private Partnership (PPP) mode,

Authors: Gopal Agrawal, Research Consultant, Emergency Management and Research Institute, Secunderabad, India. e-mail: gopal_agrawal@emri.inDr. Biranchi N. Jena, Senior Partner-Research, Emergency Management and Research Institute, Secunderabad, India. email: biranchi_jena@emri.in

EMRI is the only organisation providing the integrated emergency services in seven states of India today and would expand to rest of the states in near future. All ambulances and pre-hospital care services are provided free of cost to those in need (EMRI, 2008).

EMRI presently has 652 ambulances in Andhra Pradesh and serving a population of 80 million in 23 districts. Apart from AP, it is also operating in Gujarat, Uttarakhand, Goa, Tamilnadu, Rajasthan, Karnataka and Assamz. EMRI responds to more than 5000 emergencies in a day and has been saved more than 30,000 lives by June 2008.

A timely response and care is essential in saving lives at the time of emergencies. Thousands of lives are threatened every year due to different emergencies (such as accidents, flood, food poisoning etc.) in absence of efficient referral pre-hospital care system. In this direction, EMRI has made history of launching emergency medical services and well expanded its services to achieve the set goals and targets during 2005-08 (see figure 1). Figure 1 shows the trend in the number of ambulances and number of lives saved by EMRI in Andhra Pradesh. A sharp rise in the number of ambulances available at EMRI is observed. Figure clearly depicts that by adding more and more number of ambulances, EMRI has set a sharp rise in the number of lives saved during 2005-08.

In this context, this study tries to look into following questions: Is there any addition to the rise in the life expectancy in Andhra Pradesh as a result of EMRI’s ‘108’ services? Whether the effort

of saving lives at EMRI is reflected by the key indicator of overall health of population i.e. Life Expectancy? The study aims to quantify the contribution of EMRI’s ‘108’ services to the rise in life expectancy in Andhra Pradesh during 2005-07.

Methods and Materials

The present study has used life saved data available at EMRI for Andhra Pradesh. To quantify the contribution of EMRI’s ‘108’ services to the rise in life expectancy, the abridged life tables for Andhra Pradesh based on Sample Registration System (SRS) Data are constructed. To get population estimates in denominator, report on population projection by technical group for Andhra Pradesh is used.

Single Decrement Life Table Methods are used to quantify the contribution of EMRI’s ‘108’ services to the rise in life expectancy in Andhra Pradesh during 2005-07. Separate Life Tables are

22 2323

constructed for each sex. Due to small number of cases of lives saved, it was not possible to classify emergency causes in a large number of categories. The detailed information about life-saved cases is provided in the appendix.

To provide the estimates for the year 2007, projection technique have been adopted. The Life expectancy has been linearly projected for both sexes for the year 2007 and the contribution of EMRI to the rise in life expectancy at birth is assessed accordingly.

Since EMRI started operations of handling emergencies in Andhra Pradesh in 2005 only, the following assumptions are made while assessing the contribution of EMRI’s 108 services to the rise in life expectancy.

• EMRI’s effort of saving lives could not be captured in the life table estimates provided by Sample registration system: there are two important reasons of making such a strong assumption. First, life expectancy at birth has shown a pre-determined trend during 2005-06. No exception addition is observed in the rise in life expectancy of Andhra Pradesh during 2005-06. Second, SRS-based life tables have a reference period of 5 years i.e. 5-year moving average of age-specific death rates are used to construct the life tables. It makes clear that EMRI’s effort of saving lives has been automatically disregarded.

• The process of declaring emergency cases as a life-saved at EMRI is sound enough and strong and reliable techniques are used to declare an emergency case as a life saved. An emergency case is declared as a life saved when a critically injured / diseased patient, availing EMRI services and transported to a hospital with appropriate pre-hospital care interventions and should have survived for at least next 48 hours from the time of incident. In addition, it should fulfill the following prerequisites:

- The case should be critical/ life threatening and should have met the predefined criteria.

- The Pre-hospital Care Record (PCR) document should be complete.

- EMT must adequately assess the victim.

- EMT must provide adequate Pre-hospital care.

- The case should have been followed up after 48 hours and patient survived at least 48 hours.

Construction of Life TableLife Table is a tabular presentation of the survivorship (i.e. life history) of a hypothetical group or population. It summarizes the mortality experience of a population and results a summary measure of the impact of mortality on population: Life Expectancy. The method for construction of a life table is described below.

nMx: Age-specific death rates of population under study. It is the basic input of life table.

xn

xnxn

MnMnq

*2**2

+=

)(*2

nxxxn llnL ++=

nMx=Total mumber of deaths in age (x, x+n) in a year

Mid-year population age (x, x+n)

Adjusted nMx=Total number of death in age (x, y + n) space in a year - No. of lives saved in age (x,x + n)

Mid - Year population age (x, x + n)

• x: Age

• lx: No. of persons survived at the beginning of age interval (x, x+n).

• nqx: Probability of dying that a person will survive to the age x but will die before completing the age of x+n.

• ndx: Number of persons survived age x but died before completing age x+n. ndx = lx * nqx

• nLx: Average number of person-years lived by a hypothetical cohort of age (x, x+n).

• Tx: Average person-years lived beyond age x. It is the cumulative total of the column nLx from bottom to age (x, x+n).

• exo: Life expectancy at age x

exo = Tx / lx

To assess the contribution of EMRI’s ‘108’ services to the life expectancy, the basic input of life table, age-specific death rates are adjusted as below:

With the adjusted age-specific death rates, new life tables are constructed and thus the contribution of EMRI’s ‘108’ services to the life expectancy is obtained.

Results and DiscussionsTable 1 presents results obtained from single decrement life tables

for both sexes in Andhra Pradesh. Results depict that ‘108’ services

provided by Emergency Management and Research Institute has

made an impact on the life expectancy at birth. Due to community

based intervention made by EMRI, the life expectancy at birth is

likely to be increased by 0.03 years in 2005 respectively followed

by 0.15 and 0.37 (projected) years in 2006 and 2007. For males,

the life expectancy at birth is expected to increase by 0.01 years in

2005 followed by 0.2 and 0.49 years in 2006 and 2007 respectively.

Contrastingly, life expectancy at birth has made addition of 0.04

years in 2005 followed by 0.09 and 0.24 years in 2006 and 2007

respectively. The results clearly depict that EMRI’s ‘108’ services

made a great contribution in the enlistment of life expectancy at

birth.

2323

ConclusionThe study reveals that the interventions made by Emergency

Management and Research Institute in providing Emergency

Medical Services has impacted the Age Specific Death Rate

(ASDR) by saving lives. The effort of saving lives is expected to

be reflected by the general health indicators of population such as

life expectancy at birth. Study found a significant contribution of

the interventions made by EMRI in pre-hospital care in the rise in

life expectancy at birth. The study raises the need of conducting

community-based studies to assess the contribution of EMRI’s

‘108’ services to the health of general population.

*Projected figures: Liner rate of projection has been adopted. **Adjusted Life Expectancy at birth obtained after incorporating life saved data in life tables.

Year Total

SRS Adjusted** Increase (in years)

2005 64.03 64.05 0.032006 64.33 64.48 0.152007* 64.53 64.90 0.37

Male

Year SRS Adjusted** Increase

2005 62.55 62.56 0.012006 62.89 63.09 0.202007* 63.0 63.49 0.49

Female

Year SRS Adjusted** Increase

2005 65.21 65.24 0.042006 65.65 65.75 0.092007* 65.64 65.88 0.24

Table 1: Adjusted and Unadjusted Life Expectancy at birth for Andhra Pradesh, 2005-07

References

Preston S. H., Heuveline P. and Guillot M. (2001). ‘Demography: Measuring and Modeling Population Processes” pub. by BlackWell Publishers, USA.

Registrar General of India “Population Projections for India And States 2001-2026”

Report by Technical Group.

Sample Registration System (SRS): SRS-based Abridged Life Tables, 2001-05, Registrar General of India, New Delhi.

Sample Registration System (SRS): SRS-based Abridged Life Tables, 2002-06, Registrar General of India, New Delhi.

EMRI: www.emri.in

24 2525

Medical Emergencies in Goa - A Preliminary Analysis

Background: Most emergencies in Goa arise due to road traffic accidents and drownings, which have been compounded by the rise in number of recorded accidents in 2007 to above 4000. It is believed that an average of 11 people meet with an accident on Goa’s roads every day and this is expected to rise by 10% by next year.

Aim: Since emergency services were launched in Goa by EMRI in the first week of September 2008, we aimed to conduct a pre-launch cross-sectional survey of medical emergencies and various types of emergencies which may present to 108 services. We also attempted to identify various modes of transport which are used to currently transport emergencies currently to hospital care.

Method: On a prospective basis, all emergencies presenting to the three government hospitals in Goa, which handle 90% of all emergencies currently, were studied on specially designed data sheets in order to collect data. Emergency

ORIGINAL RESEARCH ARTICLE

Abstract:

Medical Technicians (EMTs) were placed in the casualty of the medical colleges and recorded the data on the data sheet. The collected data was then analyzed for stratification and mapping of emergencies.

Results: GMC Hospital attended to majority of emergencies (62%), which were mainly of the nature of accidents or assaults (17%) and fever-related (17%). Most emergencies were non-critical and were transported with the help of cars (17%), taxis (17%) and buses (17%). Maximum emergencies also presented from Salcette and Bardez, and occurred among young males in the age group of 19-45 years.

Conclusion: Potential emergency services need to target young males with higher concentrations required in Salcette in South Goa and Bardez in North Goa.

Key Words: Emergencies; Goa; Mode of Transport; Outcome

Dr. Saddichha SahooDr. Mukul Kumar Saxena

2525

Introduction:Goa, India’s smallest but richest per capita state, with a population

of 1.3 million people, became a part of India only in 1961, before

which it was governed directly from Portugal. The state of Goa

consumes a large quantity of alcohol and has also accepted alcohol

as a social beverage, the repercussions of which are obvious today.

One of the most serious of these has been the massive increase in

the number of road traffic accidents and accidental drownings.

A rapid explosion of road traffic accidents has been observed with

2,800 recorded accidents in 2001 doubling to above 4,000 in 20071.

In the year 2007, there have been about 4,000 accidents, an 8%

rise over last year with more than 320 persons killed, a rise of over

6% over the previous year2. It is believed that an average of 11

people meet with an accident on Goa’s roads every day and this

is expected to rise by 10% by next year. The Police Department

has reported that till date in 2008, there have been approximately

150 fatal accidents3. Most accidents involve mainly 2 wheelers in

Goa and occur around 8 pm in the night. In addition, there have

been at least one or two drowning deaths per week accounting for

a large number of accidental deaths in Goa. The Director, Goa

tourism department has reportedly informed the media that most

drownings are fatal due to lack of medical attention at the right

time4. A large number of both forms of accidental deaths have

been linked to the wide epidemic of substance use, which in turn

increases both mortality and morbidity rates. Currently, transport

of emergencies is being done by public transport including auto-

rickshaws and taxis.

Now that emergency services have been newly launched in Goa by

EMRI, it is vital that a pre-launch cross-sectional survey of medical

emergencies which may present to 108 services be carried out in

order to understand the complexities involved so that these may be

targeted by the 108 emergency services. In addition, future studies

may be designed to study the impact that 108 services has had on

mortality rates once baseline data is collected.

Authors:1. Dr. Saddichha Sahoo, BA MBBS DPM, Partner, Division of Clinical Research, Emergency Management and Research Institute, Secunderabad, India. Ph: +919000013618 e-mail: saddichha_s@emri.in

2. Dr. Mukul Kumar Saxena, MBBS MS (Gen Surgery), Senior Partner, Division of Clinical Research, Emergency Management and Research Institute, Secunderabad, India. e-mail: mukul_saxena@emri.in

Aims and Objectives:This study attempted to

1. Identify various types of medical emergencies which may

present to 108 services.

2. Identify specific variables associated with these emergencies in

order to put in place additional measures to reduce number of

deaths.

3. Identify and target specific causes for intervention.

4. Identify various modes of transport which are used to transport

emergencies currently to hospital care.

Method:Using a stratified random sampling design, records of all medical

emergencies presenting to the three government hospitals, namely

Goa Medical College Hospital (GMC), Asilo Mapusa and Hospicio

Margoa, were prospectively studied on specially designed data

sheets in order to collect data. These hospitals currently serve as

primary referral centre for nearly 90% of all emergencies. Trained

paramedic personnel or EMTs were utilized for the purpose of data

collection after a detailed training on using the data sheet. Once

trained, these EMTs were then placed in the casualty ward of the

three government hospitals in three continuous 8-hour shifts. Data

was collected over a 4 day period from 01st Sep to 04th Sep 08,

with a 24 hour round-the-clock collection ensuring that no cases

went missing. All data so collected by the end of study period

was entered into a database and further analysed to detail type of

emergency, location of emergency, transport of emergencies and

other variables associated with medical emergencies.

Results:A total number of 360 emergencies were seen over a 60-hour period. A

majority of the emergencies were handled by GMC (62%) followed by

Asilo Mapusa (23%) and Hospicio Margoa (15%). A higher incidence

of emergencies was also noted among males (64%) and in the 19-30

26 2727

Figure 2: Types of emergencies

Types of emergencies in Goa

17%

Abdominal pain

Accidents and assaults

Cardiac-related

Poisoning and overdose

Falls and fractures

Pregnancy-related

Fevers

Animal bites

Head injuries

Unconsciousness

Others

1%10% 7%

17%

5%

37%

5%

18%8%

9%

Age distribution of emergencies in Goa

Below 10 years

11-18 years

19-30 years

31-45 years

46-60 years

Above 60 years38%

21%15%

7%

12%

7%

Figure 3: Status at hospital of emergencies

Critical

Non-Critical

Expired

9%

1%

Status at hospital of emergency victims

90%

year age group and 31-45 year age group which accounted for nearly 60% of all emergencies (Fig. 1).

Figure 1: Age distribution of emergencies

When categorized into types of emergencies, most emergencies were either due to vehicular accidents and assaults (17%) or fever-related

(17%). The other types of emergencies presenting to hospitals were mainly cardiac-related causes, falls and fractures, pregnancies and

abdominal pain. (Fig. 2)

After being brought to hospital and on evaluation, most emergencies were non-critical in nature (90%). However, about 1% arrived dead

at the hospital. (Fig. 3)

2727

Currently, most emergencies are transported to the hospital with the help of cars (17%), taxis (17%) and buses (17%). The other major

modes of transport were autos, 2-wheelers and ambulances. (Fig. 4)

Transport of Emergency in Goa

Auto

Car

Bus

Wheeler

Taxi

Ambulance

Others

17%

16%

14%

17%

11% 13%

12%

Figure 4: Mode of transport of emergencies

A stratification of emergencies by talukas resulted in the maximum

emergencies presenting from Salcette and Bardez, each accounting

for above 20% of all emergencies. Tiswadi accounted for about

15-20% of emergencies, while a lower incidence was seen in the

remaining talukas. (Table1)

Discussion:This study attempted to perform a rapid cross-sectional situational

study of factors contributing to medical emergencies in Goa.

Using a sampling design spread over a duration of four days and

covering about 90% of all emergencies in Goa, this study attempts

to give a current view of medical emergencies in the state. Since

the casualties record all emergencies presenting to the hospitals,

a round-the-clock collection of data ensured that all emergencies

were accounted for. Further, the presence of trained paramedic

personnel ensured that emergencies were handled with sensitivity

and accurate clinical data was collected.

The results observed that the majority of all emergencies were

received by the Goa Medical College (GMC) Hospital. Located in

Panjim, this hospital serves the whole of Goa and has the maximum

number of facilities and specialties available. Its no surprise

therefore that GMC Hospital attracts all kinds of emergencies and

from all places in Goa including the border areas of Sawantwadi in

Maharashtra and Karwar in Karnataka. Emergencies were also noted

in the majority of males and in the age group of 19-45 years, making

this a vulnerable age group to be targeted for prevention policies.

Further, since young males are also most vulnerable to vehicular

accidents and assaults, this also makes this type of emergency as the

most common one followed by febrile emergencies. In addition,

cardiac-related emergencies were also frequently reported, making

this a high priority area to target during service delivery.

The highest percentage of emergencies brought to hospitals were

non-critical, however about 1% expired, potential lives which may

be saved once 108 services have started. In the current scenario,

this translates to 4 lives saved or about 1/day. Transport of

emergencies also takes use of available vehicles with cars and

taxis accounting for most of them. Ambulances accounted for

just a tenth of all emergencies brought, a situation that is likely

to change in the future. Since Salcette and Bardez accounted for

the highest emergencies, a positioning of paramedic personnel and

ambulances with easy access to these areas would go a long way in

saving potential lives.

Table 1: Distribution of Emergencies

Taluka Incidence of Emergency

Pernem Sanguem Satari Bicholim > 5%

Quepem Mormugao Ponda

5-10%

Tiswadi 15-20%

Bardez Salcette

>20%

28 2929

Conclusion:Potential emergency services need to target young males with

higher concentrations required in Salcette in South Goa and Bardez

in North Goa. Emergency services need to be also geared to handle

vehicular accidents and cardiac-related emergencies, with both

speed of service and quality of medical care being essential to save

lives.

References:1. Accidents in Goa. Directorate of Planning, Statistics and

Evaluation Panaji-Goa.2. Accident Scenario in Goa. Goa Police. Available at

http://goagovt.nic.in/police/html/acc_page.htm3. Road accidents in Goa on a high. Times of India 21 Jul 2008. 4. List of unsafe Goa beaches being prepared. The Hindu.

03 May 2007.

2929

An Epidemiological Study of Emergencies Resulting from Snakebites in Andhra Pradesh

Abstract: Background & Objectives: Snakebite is an important and growing cause of morbidity and mortality in different parts of the world, especially in south Asian countries. It has been observed that most of the snakebite victims suc-cumbe to death due to non-availability of quick and quality emergency medi-cal support. This study was undertaken to find out the epidemiological profile of the snake bite victims and to examine association of socio-demographic and other variables with the survival of the victims.

Material and Methods: 5155 snakebite emergency cases were reported to Emergency Management & Research Institute (EMRI) from the state of Andhra Pradesh in 2007. Based on the variables required for the study and their availability, 877 snakebite cases were selected from Pre-Hospital Care Record (PCR) of EMRI for the current study. Variables like age, gender,

Dr. Biranchi N.JenaDr. Nafeez S.Umar

ORIGINAL RESEARCH ARTICLE

area, time of bite, season and response time etc., are studied with reference to the survival of the victim.

Results: More Snakebite cases are reported from rural area as proportion of victims in rural and urban area is found to be 12:1. Males were more victim-ized in the event of snakebite (57%) as compared to the females. The results observed that 325 (37%) of the total snakebite victims are in the age group 20-30 years. About 47 % of cases were observed in the period from June to September which coincided with maximum rainfall in Andhra Pradesh and quantum of rainfall is found to be highly correlated with snakebite cases re-ported to EMRI. The major symptoms observed at the time of attending the snakebite cases were difficulty in Mobility, Swelling and Bleeding.

Key words: Snakebite victims - epidemiological profile

30 3131

Introduction:

Snakebite is a widely distributed but neglected condition. It is

estimated that over five million people in the world are envenomed

by snakebite1. In Asia alone, it has been estimated that four million

snakebites occur each year, of which approximately 50% are

envenomed, resulting in 1,00,000 annual deaths2, 3. On an average

annually nearly 2,00,000 persons are bitten by snakes in India and

35,000-50,000 of them die4, 5. In India, most of the snakebites

are encountered in rural areas and this has been linked with

environmental and occupational conditions6.

Snakebite is an important and serious medical problem in many

parts of India. However, reliable data for the morbidly and

mortality are not available since there is no proper reporting system.

Moreover, the records of the large number of cases do not come

to official statistics as people seek traditional methods of treatment.

Most of the studies in India deal with clinical and management

aspects. Epidemiological studies related to snakebite are very few.

The present study was undertaken with the objectives to find out

the profile of the snakebite victims and to examine association of

various socio-demographic and other related variables with the

survival status of the snakebite victim.

Material and Methods:The present study is based on the all the reported emergencies

associated with snakebites reported to the Emergency Management

and Research Institute (EMRI) from January 2007 to December

2007 in Andhra Pradesh.

The current study examined the association of socio and

demographical factors with the survival status of snakebite victims

in Andhra Pradesh. Based on the requirement of the study, only

877 snakebite cases were selected for the study out of total 5,155

snakebite cases reported to EMRI in 2007. Pre-hospital Care

Record (PCR) was the major source of data for the study. PCR was

introduced along with the operation of Emergency Management

and Research Institute (EMRI) providing the pre-hospital care while

transporting the emergency patients to the appropriate definite care

Authors:Dr. Biranchi N.Jena, Senior Partner, Research and Analytics, Emergency Management and Research Institute, Secunderabad, India. email: biranchi_jena@emri.inDr. Nafeez S.Umar, Associate Partner, Research and Analytics, Emergency Management and Research Institute, Secunderabad, India. email: shaiknafeez_umar@emri.in

units. PCR is an instrument which captures the socio-economic.

demographic variables of the emergency victims along with pre-

existing ailments and the type of medical intervention given to

victims as the pre-hospital care. Since the PCR forms are filled by

the qualified and trained Emergency Medical Technicians (EMTs),

the quality of data is assumed to be good for research projects.

For the purpose of the study, the survival status of victim is defined

as whether the emergency victim is alive or not after 48 hours of

providing the emergency transport with pre-hospital care to the

patients. EMRI has a robust process in collecting the survival status

of the victims after 48 hours of the incident. EMRI collects the

information on survival status in four major categories viz. “alright

and discharged from hospital”, “Stable, out of danger but still in the

hospital”, “critical and still in the hospital” and “expired”. Probable

envenoming was defined as the occurrence of at least one of the

following symptoms: Bleeding, Difficulty in Mobility, Difficulty in

Breathing, Difficulty in Vision, Difficulty in Speech, Swelling, and

Vomiting.

Frequencies and proportions were used to describe the characteristics

of the people with snakebite. Chi-Square test is used to examine the

statistical significance of the association of different variables with

survival status. Statistical analyses were performed using SPSS 16

version.

Results:It was observed that the males (57.1%) were bitten more than the

females (42.9%). Area wise, most of snakebite cases occured in

rural areas (92.4%) than in urban areas (7.6%). Thus the proportion

of snakebites in the rural and urban was found to be 12:1. There

was no variation of snakebite cases in different incident locations

(outside residence, inside residence). The victims had a mean age of

34 years and agewise distribution of cases showed that the majority

(32.4%) belonged to 20-30 years age group, next common age

group was 30-40 years. As far as the fatality out of the snakebite

cases are concerned, 2.9%of the snake bite victims died within 48

hours of the incident. [Table-1]

3131

Most of the snakebite cases were reported during the middle monsoon (June-Sept) (46.9%) [fig.-1].

Figure 1: Area-wise and monthwise variation in Snakebite cases reported to EMRI

250

Months

Rainy Season

Rural

Urban

Total

200

150

100

50

0

Snak

ebite

s

Janu

ary

Febr

uary

Mar

ch

Apr

il

May

June

July

Aug

ust

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Table 1: Descriptive statistics for Snakebite cases in Andhra Pradesh

Parameter Frequency (%)

GENDER

Female

Male

376 (42.9)

501 (57.1)

AREA

Rural

Urban

810 (92.4)

67 (7.6)

INCIDENT LOCATION

Outside Residence

Residence

443 (50.5)

434 (49.5)

OCCUPATION

Daily Wage Workers

Housewife

Others

Student

489 (55.8)

147 (16.8)

122 (13.9)

63 (7.2)

AGE

0-10

10-20

20-30

30-40

40-50

50 & above

29 (3.3)

114 (13)

284 (32.4)

217 (24.7)

119 (13.6)

114 (12)

SURVIVAL STATUS

Fatal

Non fatal

25 (2.9)

852 (97.1)

Table 2: Distribution of Snakebite cases by different time period

Time/Period

Dry Season (Oct-May) *

Rainy Season(June-Sept)

Frequency(%)

466 (53.1)

411 (46.9)

MONSOON

Winter (Jan-Feb)

Pre Monsoon (Mar-May)

Middle Monsoon (June-Sept)

Post Monsoon (Oct-Dec)

6 (0.7)

68 (7.8)

411 (46.9)

392 (44.7)

DAY-NIGHT

Day

Night

636 (72.5)

241 (27.5)

TIME OF BITE

Day (6-12)

Evening (12-18)

Morning (18-24)

Night (24-6)

331 (37.7)

241 (27.5)

239 (27.3)

66 (7.5)

RESPONSE TIME (IN MIN.)

0-10

10-30

30 & Above

144 (16.4)

307 (35)

426 (48.6)

MONTH

January

February

March

April

May

June

July

August

September

October

November

December

2 (0.2)

4 (0.5)

19 (2.2)

37 (4.2)

12 (1.4)

16 (1.8)

83 (9.5)

119 (13.6)

193 (22)

232 (26.5)

114 (13)

46 (5.2)

Majority of the snakebites occurred at day time (72.5%) than the night time (27.5%). As it is already noticed that more than 90% of the cases are reported from rural area, responding to 48% cases took more than 30 minutes, while 35% cases the emergency services provided in 10-30 minutes and 17% cases it was less than 10 minutes. [Table-2].

32 3333

Table 7: Association tables for Presenting Symptoms and Pre care hospital

Presenting Symptoms Pre-care Hospital

Unconscious

IV Fluids Oxygen Wound care

14 (8.731 *) 20 (6.01 *) 4 (0.700 ns)

Swelling 70 (7.495 *) 116 (1.482 ns) 52 (4.643 *)

Vomiting 30 (3.948 *) 52 (4.20 *) 19 (0.348 ns)

Bleeding 34 (0.365 ns) 59 (0.650 ns) 46 (33.997 **)

Difficulty in Mobility 103 (1.118 ns) 210 (11.459 **) 71 (0.042 ns)

Shock 11 (0.253 ns) 19 (0.016 ns) 9 (0.569 ns)

Difficulty in Breathing 21 (0.793 ns) 44 (7.268 **) 10 (1.354 ns)

Difficulty in Vision 12 (0.832 ns) 20 (0.095 ns) 7 (0.017 ns)

Difficulty in Speech 36 (3.81 ns) 61 (1.980 ns) 20 (0.086 ns

Table 3: Association of snakebite cases with rainfall

*Source: India Metrological Department, Mausam Bhavan, Lodhi Road, New Delhi

It was observed the cases of snakebite and quantum of rainfall are highly correlated (the correlation coefficient value is 0.7473, which is statistically significant at 0.01 levels.). [Table-3]

Note: Parentheses indicating Chi-Square values**: Significant at 0.01 levels *: Significant at 0.05 levels .Ns: Not significant at 0.05 levels

The most affected anatomical area was reported as lower limbs (56.3%) followed by upper limbs (20.9%). Information not available accounted for (18.6%) of the total cases. [Table-4]

The present study was analyzing the significant association between

the different types of socio and demographic variables with their

survival status. It was observed that survival status is significantly

associated with monsoon (p<0.01). As it was observed that most of

the snakebite cases were reported during the monsoon, the survival

rate was 96% during monsoon, where as the rate is improved to

98.5% in post monsoon. It was also observed that the survival rate

was not significantly associated with time of reporting (day/night).

The survival rate was higher (99%) for those cases reported in day

time than those cases reported at night time (93%). A minor variation

was noted in the response time while handling the cases in daytime

and night. The response time in 51% of the total cases handled

during night was more than 30 minutes, where as the ratio was only

47% in day time. However the response time was not found to be

significantly associated with the survival rate. [Table-5]

Major symptoms recorded in PCR were difficulty in mobility

with Swelling bleeding, difficulty in speech and vomiting. Out of

877 victims, there were 259 (30%) victims having two symptoms

present and 247 (28%) having only one symptom visible at the time

Table 4: Distribution of Anatomical area of injury for the reported Snakebite cases to EMRI

Anatomical area of injury @ Snakebite (%)

Upper LimbsLower LimbsMultiple regionsInformation not available

183 (25.63)494 (69.18)37 (5.00)163 (18.6)

Total 877 (100)

Monsoon Snakebite Rain fall in (mms) cases in AP, 2007 *

Winter (Jan-Feb) 6 4.6

Pre Monsoon (Mar-May) 68 44.3

Middle Monsoon (June-Sept) 411 767.2

Post Monsoon (Oct-Dec) 392 168.3

Correlation Coefficients 0.7473, ( P<0.01)

of providing the pre-hospital care. One hundred fifty one victims (17%) had no symptoms recorded. [Table 6]

In case of snakebite, major pre-hospital care intervention includes IV fluids, Oxygen and wound care. Chi–square test is performed to check the association between different presenting symptoms on the victims and the pre-hospital care. It is observed that difficulty in mobility was major symptoms at the time of pre-hospital care given and oxygen as a pre-hospital care is significantly associated with difficulty in mobility (p<0.01). IV fluid intervention is also

significantly associated with symptoms like unconscious, swelling and vomiting (p<0.05). [Table-7]

Number of Symptoms at the time of Snakebite Frequency (%)

Nothing recorded 151 (17.0)

Single Symptom 247 (28.0)

Two Symptoms 259 (30.0)

Three or more Symptoms 226 (26.0)

Table 6: Number of Symptoms seen at the time of snakebite

Table 5: Association between Socio-Demographic vari-ables with survival statusParameter χ2 value for association- ship with survival status

Response time 2.275 nsDay/Night 0.162 nsTime of reporting 4.448 nsMonth 34.52 nsMonsoon 24.734 **Victim’s age 6.964 nsGender 0.013nsIncident Location 4.696 nsOccupation 2.292 ns

Note: **: Significant at 0.01 levels Ns: Not significant at 0.05 levels

3333

Discussion:On an average annually nearly 2,00,000 persons are bitten by snakes in India and 35,000-50,000 of them die because of complications following snakebites 4, 5. This translates the mortality rate of 175 to 200 per 1000 snakebite cases. The current study indicates a mortality rate of 29 per 1000 snakebite cases. The fatal outcomes are more likely when the victim delayed to seek the treatment from the nearest reference treatment centre for snakebite6. The most common causes of delay in seeking the medical intervention were an initial consultation of a traditional healer and lack of available transport6. The low mortality rate noted from the present study indicates effective pre-hospital care and provision of quick transport facility which prevents the delay in getting admitted in the nearest health centre.

Highest number of bites recorded during June to September in the present study is similar to that recorded earlier from Pondichery2. The possible reason for majority of the snakebites in rainy season may be attributed to the flooding of rain water in the dwelling places of snakes, thus causing their dislodgment. Consequently, human population becomes accidental victim to the snakebite. Further, the situation is aggravated by the propinquity of rodents near the human habitat, thus increasing the risk of snake-bite. In occupation wise 55.8% of daily wage workers were affected by snakebite, who are bitten while working in agricultural fields and the daily activities.

In the present study, snakebite victims were observed in almost all age groups, the majority being in 20-40 years and the average mean age was 34 years. In the previous studies reported, the commonly affected age groups were observed to be 10-40 years in Nepal 7, 15-44 in Pakistan 8 and 6-40 Zimbabwe 9.

Approximately one-third of the patients in a study conducted in Nepal had a wound requiring dressing or surgery6. In the-present study the wound care (dressing) was carried out in 27% of the victims, indicating that wound care is an important aspect of the pre hospital care of medical emergencies pertaining to snake bites. For Lower limbs were most frequently affected (56.3%) and these accidents could have been easily avoided by using boots at the time of laboring in the field, Upper limbs were less frequently affected (20.9%) by snakebite cases.

Survival of the snakebite victims is very important to speed and quality of the pre-hospital care. However the effectiveness of the pre-hospital care and definite care at hospital is often delayed as, most of the victims may consult traditional healers before seeking medical services.

In the current study, three major important pre-hospital care interventions were:

1. IV Fluids - The IV Fluids effectively works for symptoms like Unconsciousness (χ2 = 8.731*, P<0.05), Swelling (χ2 = 7.495*, P<0.05) and Vomiting (χ2 = 3.948*, P<0.05).

2. Oxygen - Oxygen was commonly administered in case where the symptoms like vomiting, difficulty in mobility and difficulty in breathing. Significant association was found with Oxygen and symptoms like Unconscious (χ2 = 6.01*, P<0.05), Vomiting (χ2 = 4.20*, P<0.05), Difficulty in Mobility (χ2 = 11.459**, P<0.01) and Difficulty in Breathing (χ2 = 7.268*).

3. Wound care-Wound care was found to be an effective pre-hospital care intervention with swelling and bleeding as there was a significant association of wound care with Swelling (χ2 = 4.643*, P<0.05), Bleeding (χ2 = 33.997**, P<0.01).

Conclusion:Snakebite as per the data available with EMRI, was seen more among adults with mean age of 34 years, male daily wage workers with peak occurrence during rainy season. IV fluids, oxygen and wound care are the more frequent and effective pre-hospital care provided by EMRI in case of snakebite. About 97% of the victims either got relieved or cured with a mortality of 2.9% within 48 hours of the incident.

References:

1. Mathew Joseph L., Gera Tarun. Ophitoxaemia (Venomous snake bite), www.priory.com/med/Ophitoxaemia.htm (accessed on October 14, 2008).

2. Srihari PLD, Rotti SB, Danabalan M, Akshay K. Epidemiologycal profile of snakebite cases admitted in JIPMER hospital. Indian J Community Med 2001; 26: 36-8.

3. Chippaux J-P, 1998. Snakebite: appraisal of the global situation. Bull World Health Organ 76: 515-524. (ISI) (Medline).

4. Ganneru Brunda, Sashidhar, RB, 2007. Epidemiological profile of snake-bite cases from Andhra Pradesh using immunoanalytical approach. Indian J Med Res 125, 661-668.

5. David AW. Guidelines for the clinical management of snake bites in the south east Asia region. WHO, Regional Office for south east Asia, New Delhi; 2005 p.1-67

6. Sanjib K.Sharma, Francois. C, Nilhambar. JHA, Patrick A.Bovier, Louis Loutan, Shekhar Koirala, 2004. Impact of snakebite and Determinants of fatal outcomes in Southeastern Nepal, Am. J. Trop. Med. Hyg., 71 (2), 234-238.

7. Buranasin P. Snakebites ar Maharat Nakhon Ratchasima Regional Hospital. Southeast Asian J Trop Med Public Health 1993; 24: 186.24.

8. Rano M. A study of snakebite cases. J. Pak Med Assoc 1994; 44:289.

9. Nhachi CF, Kasilo OM. Snake poisoning in rural Zimbabwe: A

prospective study> J Appl Tocicol 1994; 14: 192-3.

34 3535

Scorpion envenomation is a public health problem in tropical and subtropical countries, especially in Africa, Middle East, Latin America and India. At times it pose a significant life-threatening acute time limiting cardiovascular emergency. Irrespective of different species of scorpion, similar cardiovascular effects are reported. Scientists working on this problem tuying to understand the pathophysilogy of severe scorpion sting by various investigations including, neurotransmitter, radioisotope study, echocardiography, haemodynamic pattern and clinical manifestations. Various regimen including vasodilators, antivenin,

Scorpion StingDr. H.S.Bawaskar Dr. P.H.Bawaskar

REVIEW ARTICLE

Abstract:

platelet activating inhibitors, inotropic support, and metabolic rectifier such as insulin and L-carnitine have been tried. Irrespective of the understanding pathophysilogy and its management the fatality remains high in rural areas due to non-approachable medical facilities and faith in village healers which delays the hospitalization. Scorpion envenoming have been underestimated as this problem faced by the world comprises the majority of underdeveloped and developing countries. Moreover, the medical attendee from poor countries may not be aware of western line of treatments of scorpion sting.

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IntroductionScorpion envenomation is a public health problem, common in certain areas of the world including Middle East, Latin America , Africa and India 1, 2, 3. Mesobuthus Tamulus (the Indian red scorpion) scorpion venom is potent sodium channel activator4. The clinical manifestations of scorpion envenomation appear to be secondary to activation of both the sympathetic and parasympathetic nervous system. In 2/3rd of victims, the main clinical manifestations of scorpion sting are local severe excruciating pain only, which radiates along the corresponding dermatomes accompanied with mild edema and local sweating at the site of sting. Systemic manifestations (vomiting, sweating, salivation, cold extremities, priapism hyper or hypotension, brady or tachycardia and ventricular premature beats or at times non-sustained ventricular tachycardia ) arenot uncommon due to envenoming by the lethal scorpion species Mesobuthius tamulus, Leiurus quinquestriatus, Androctonus mauretanicus, Buthus occitanus, Centruroides, A crassicauda, Tityus zulianus Tityus serrulatus1, 3, 4. Similar cardiovascular manifestations have been reported irrespective of different species of scorpion4. Morbidity and mortality due to scorpion sting is related to acute pulmonary edema, cardiogenic shock and multi-organ failure. A study of 434 cases during a ten year period at the national guard hospital in Riyadh showed 92% had local pain, 25.6% had systemic involvement, hypertension in 17%, Tachycardia in 4% 5. In a study from western Maharashtra, we have reported 526 cases studied between 1984-1991 of which 236 (45%) had hypertension, 27/(5%) had hypertension with pulmonary edema, 139 (27%) had pulmonary edema, 96 (27%) demonstrated tachycardia and 28 (5%) died. A report from ministry of health in Colina state of Mexico recorded 13,223 cases in the year 2000-2001. Of these 49% were a mild clinical, 33.8% had moderate and 17% had severe manifestations. Children exhibit more severe manifestations 7. Venezuela reported children with high fatality8. 13 out of 78 cases died due to scorpion sting as stated in a report from Mahad region9. In rural hospitals from western Maharashtra, India 3,546 scorpion sting cases are reported in one year, of these 542 had systemic involvement10. Similar report from Pondicherry, Andhra Pradesh and Karnataka states of India.10,11,12

Opinions differ regarding correct treatment of scorpion envenomation7. Recently WHO reported that the truth of scorpion sting envenoming is not known because many cases do not seek medical attention. Moreover, scorpion envenoming

Authors: Dr. H.S.Bawaskar & Dr. P.H.Bawaskar Bawaskar Hospital and Research Center, Mahad Dist- Raigad Maharashtra India 402301. email:himmatbawaskar@rediffmail.com

accident occurring in villages of tropical and subtropical countries and many countries including India it was not modifiable disease hence the actual statistical data is scarce. Moreover, majority of the victims attend in the village healers or tantriks or quacks remain unregistered. It has been estimated that there are approximately 1 million stings per year. In Mexico alone 2,50,000 scorpion stings are reported yearly, in Tunisia 40,000 stings, 1,000 hospital admission and 100 deaths are reported each year. There is a high incidence in other parts of north Africa, the Middle East13 , India and Latin America. In Khuzestan, southwest Iran, scorpion sting is the fourth leading cause of death attributed to Hemi scorpion lepturus 14. In Brazil, 37,000 scorpion sting and 50 deaths were reported in 2005 13. This incidence indicates that envenoming by scorpion sting is an important, yet neglected, health issue in affected parts of world 13. Scientists are keen in treating reporting and studying the snake bite more than scorpion envenoming. However, the clinical research done in tropical countries is often neglected by health authority is and unfortunately there is no consensus regarding management of scorpion sting similar to snakebite (WHO personal communication).

Scorpion antivenin is widely used in many countries such as Brazil, Saudi Arabia, Mexico 15, 16, 17, 18, 19 , 20, 21, 22, 13, 24, 25, 26. The acceptance of scorpion antivenin as an effective treatment in scorpion sting is based mainly on its efficacy in experimental studies. Scorpion antivenin is no better than placebo reported from Tunisia 24. The beneficial effects of antivenin in protecting victims against severe scorpion sting is still questionable 27,28,29

Scorpions have been recognized by a sting with severe excruciating pain long lasting and rarely threat to the life. They are one of the oldest known terrestrial arthropods. Fossil scorpions found in Paleozoic strata 430 million year old appear very similar to present species30. They survive heat, drought, can withstand freezing condition for weeks, desert conditions and starvation for months and total immersion in water for days. This remarkable power of adaption, make them many a time independent of ecological condition and gives the race an unbroken continuity. They are strictly carnivorous, feeding on insects. Scorpions are viviparous, give birth to the young ones and sometimes the mother tries to eat the young, but more often, the young ones nibble the mother to death (cannibalism) 31. Scorpions belong to venomous

36 3737

arthropods in the class Archnida. They shelter under bark of trees, dry firewood or cow dung, in a piles of bricks, paddy husk, beddings, loose tiles of hut and at times in the shoe left empty over night and pockets of trousers and shirt, craves of window and doors. In tropical countries sparrows usually bring small scorpion along with the dried grass to build up a nest over window in a pucca house. Farmers and farm labors are often stung by scorpion during handling of paddy husk, harvesting grass over bund in the months of September to November3,32 . Travelers while walking barefoot in the desert are more prone to this painful lifethreatening accidents (Fig.1).

There are around 1400 species of scorpions but only 46-50 of

these are potential lethal to humans (Fig.2)32.

The Lethal species belong to Androctonus (Morocco and Senegal eastwards to India, Buthus (Mediterranean, Middle East and East Africa), Hottentotta (Northern Africa and Middle East), Leiurus

Figure 1

Figure 2

Figure 3

(East Africa and Middle East), parabuthus (Sudan to South Africa), Mesobuthus (India, Southern and Central Asia), Tityus (South America), Centruoides (USA, Mexico, and Central America).Hemiscorpion lepturus (family scorpiodae) a dangerous species seen in Iran. Palmaneus garvimanus a cactoid species scorpion is bigger in size compare to other species and is black in color it causes severe pain with mild sweating 3,33 (Fig.3)

VenomTail end of scorpion content two telson glands actively secret the venom at the time of sting which is injected in a prey by sharp stinger. All scorpion species secret venom. Venom is a mixture of various active substances of these neurotoxins 34. Neurotoxins consist of different small size proteins with a sodium and potassium cations which interfere the neurotransmitter in the victim. Venom actions on neurotransmitter are rapid and fast. It contains a peptide neurotoxin that open the Na+ channels (B–toxin). Sodium is primarily an extra cellular ion maintaining electric voltage difference across the cell membrane. Venom depolarizes the cell membrane and it also inhibit the deactivation of Na+ channels (alpha- toxin). There is a massive release of endogenous catecholamine in to circulation due to delayed inactivation of sodium neuronal channel by venom (4). Thus venom of the Mesobuthus Tamulus (the Indian red scorpion), Buthus Martensi (chene’s scorpion) and Leiurus Quinquestriatius (Israel scorpion) causes autonomic storm by stimulating both sympathetic and parasympathetic nervous system. Charybdotoxine is the another component of the venom inhibits the calcium dependent K+ channels, similarly iberiotoxin isolated from Mesobuthus Tamulus has similar action on K + channels35,36 The venom of leiurus species includes chlorotoxin which acts on Chloride channels. Scorpion venom also contains serotonin which causes local pain at the site of sting. The venom of Tityus species a kallikrenin inhibitor causes raised bradykinin37, 38. Venom of Tityus Serrulatus from Trinidad is pancreotoxic responsible for

3737

development of acute pancreatitis. Hemi scorpion leptirus is the most dangerous scorpion of Khuzestan, south west, hot and humid province of Iran13. Venom causes severe local tissue necrosis, renal failure and cardio respiratory arrest13.

Clinical manifestations Clinical effects of the envenoming depend upon the species of scorpion and dose of venom injected at the time of sting. The severity of envenoming is related to age, size of scorpion and season of sting. High incidence of pulmonary edema and fatality are seen in the monthes of June, September and October 3, 9, 39.

Irrespective of different species with few exception (Iran and Trinidad) the cardiovascular manifestations due to envenoming are similar 1, 3, 6, 17, 24, 40 The early or premonitory clinical manifestations as result of autonomic storm are characterized by vomiting 34%, profuse sweating from all over body 45%, priapismin males 28%, cold extremities 71% and mild tolerable pain which becomes severe, when extremities became warm is a sign of recovery 41. On the clinical presentations or course in hospitalized patients are divided into 1 - Severe local pain only 2 - systemic involvement.

Local painSevere excruciating pain is the only clinical manifestation seen in 35% of cases. 57%, 33%, 11% lower, upper extremities and other parts of the body is the site of sting respectively. Severe pain radiates along with corresponding dermatomes. Due to pain intolerable, inconsolable crying of the child, sudden onset is a diagnostic sign especially in a early darkness when one can not find the culprit. Children are confused and anxious due to pain. Local edema, urticaria, fasciculation and spasm of underneath muscle at the site of sting due persistent stimulation of pain conducting receptors and liberated serotonin29, 30. Due to pain there is transient bradycardia, transient rise in blood pressure and mild sweating but extremities are warm3. Sudden tap at the site of sting induces severe pain and sudden withdrawal of the part is diagnostic of scorpion sting called TAP sign .

Systemic manifestations Clinical manifestations depend upon time lapse between sting and hospitalization or treatment received at periphery32. According to clinical manifestations, they are divided into three grades of II, III and IV. All cases had initial sign and symptoms suggestive of autonomic storm3. Grade II – hypertension or transient hypotension, Tachycardia, bradycardia, and cold extremities Grade III – hypertension, hypotension, tachycardia and pulmonary edema or Massive pulmonary edema, respiratory failure. Grade IV- tachycardia, hypotension, pulmonary edema with warm extremities called warm shock.

Hypertension45% of victims with systemic involvement had raised blood

pressure soon after sting. Blood pressure is ranges between 140/90

to 180/130 mm hg. Children look agitated confused and had

propped up eyes and puffy face39. Hypertension noted in victim

reported 15 minute to 11 hour after sting. Majority of cases had

headache, chest discomfort, and perioral parasthesia.

Transient initial hypotension is due to dehydration caused by

excessive sweating, salivation and vomiting which is further

aggravated by hot climatic condition of tropical and subtropical

countries, while post adrenergic hypotension is due to depletion

of catecholamine which is due to over stimulated alpha-1 receptors 32, 42, 43.

Pulmonary edema Pulmonary edema occurs in 27-30% cases with respiratory failure.

Pulmonary edema develops within 30 minute to maximum 10

hours after sting. 8% cases reported in an acute life-threatening

massive pulmonary edema. Rapid onset of pulmonary edema

within two hours of envenoming is often accompanied with

severe hypertension. Parasternal sustained systolic lift due to

sudden rise in pulmonary pressure with right ventricular after

load3,32. Sudden onset of breathlessness, intractable cough, poor

peripheral oxygenation, ice cool extremities, tachycardia with low

volume thread pulse, central cyanosis, bilateral moist rattles heard

all over chest, with loud summation gallops and transient systolic

murmur due to mitral valve incompetence auscultation over pre-

cordium. Intractable cough, with massive expectoration of blood

mixed froth from mouth and nostril, with central cyanosis, hypo or

hypertension and loud death rattles sound heard few feet away from

patient suggestive of massive pulmonary edema42.

Victims reported late > 6-10 hours and had persistent pulmonary

edema or treated by peripheral doctors with excessive intravenous

fluids, steroids, antihistamines, and atropine, diuretic. Such victim

developed hypotension, tachycardia, air hunger and prolonged

poor tissue circulation with accumulation of anoxic metabolites

in the circulation resulting in paralysis of capillary sphincter

(vasodilatation) and look cadaver pale. Patients are with irritable,

disoriented with or without pulmonary edema suggestive of warm

shock45, 46, 47.

58% victims who reported within 8 hours of sting had heart rate

110-200 (mean 143) per minute with mean blood pressure 60-113

(mean 85) with cold extremities with or without pulmonary edema,

38 3939

42% cases usually reported 8-26 (mean 150 hours of sting with

marked tachycardia 140-200 (mean 165) with hypotension systolic

blood pressure 50-90 mm hg with warm extremities with or without

pulmonary edema (warm shock)47. Reappearance of local pain at

the site of sting which was mild or absente on arrival suggestive of

recovery. 41 Hemiplegia, cerebral edema, disseminated intravascular

coagulation, due to scorpion sting have been reported. Fatality is

high, once neurological complications such as coma, convulsions,

miosis, mydriasis occurred.48, 51, 52, 53

Abdominal pain, nausea, vomiting are common signs and

symptoms of scorpion envenomation in older children and adults

also attributed to acute pancreatitis with raised level of plasma

immune-active cationic trypsin seen due to envenoming by Tityus

Trinitatatis and Leiurus Quinquestritus54 and due to Mesobuthus Tamulus

envenoming. Scorpion envenoming rarely causes acute renal failure.

However ill treated, delayed reporting of a case developed and dies

due to multi-organs failure 55.

InvestigationLeukocytosis 11000-26000 per/cu.mm, increase in troponin 1 and

other cardiac enzymes, raised inteleukin, tumor necrosis factor,

platelet activating factor.56, 57 Rennin, angiotension II, and urinary

and serum catecholamine levels.58

X-Ray chest showed typical picture of pulmonary edema with

batwing appearance (Fig. 4 and 5). At times unilateral distribution of

pulmonary edema with air bronchogram and cardiomegaly.17, 45, 59

Figure 4: Batwing: A sign of pulmonary oedema

Figure 5: Batwing after 4 hours

Electrocardiogram ECG)- ECG is most easy available tool in rural setting. No single victim with systemic involvement had normal ECG. Sinus bradycardia seen in early hypertensive cases with heart rate 42-60 per minute which persisted for 3-4 hours, ventricular premature contraction, couplets, transient runs of ventricular tachycardia and rarely a fatal lethal ventricular arrhythmia, sinus tachycardia, injury to conducting system in form of left anterior hemiblock (Fig. 6), right bundle branch block , left bundle branch block (Fig. 7), complete heart block, marked tented T waves mimicking like a acute myocardial infarction pattern (Fig. 8), ST elevated with non Q infarction pattern, PQRST alternans have been reportedzzz. Subsequent broad wide base with round top T wave suggestive of delay repolarization with prolonged QTC (450 – 650 milliseconds) accompanied with asymptomatic bradycardia and hypotension observed 36-48 hours of hospitalization and persisted for next five days. T wave inversion persists for > four weeks. Despite good clinical condition of the victim, ECG showed marked changes 60, 61, 62, 63, 64, 65.Figure 6:

3939

systemic, vascular resistance with pulmonary edema was seen in severe scorpion sting, however, severe hypotension depends upon the fluid balance. Hypotension and shock with warm extremities occurs terminally due to biventricular dysfunction and terminal vasodilatation (warm shock). Similar hemodynamic pattern was reported from Tunisia, Brazil and Israel47, 65, 66, 68, 69.

Patho-physiologyDelayed inactivation of neuronal sodium channels results in acute autonomic storm. Sudden liberation of endogenous catecholamine resulted in initial transient rise in blood pressure, bradycardia and increased vascular resistance. Alpha-1 receptors stimulation plays an important part in the pathogenesis of acute pulmonary edema due to scorpion sting70 . Accumulation of calcium in the heart caused by the action of a liberated catecholamine result in increased requirement of oxygen to myocardium with systolic and diastolic dysfunction.64, 70 There is also experimental evidence of impaired coronary perfusion.71 In addition, the coronary circulation is further compromised due to raised level of rennin and angiotensin II.37 There is no significant evidence of direct effects of venom on myocardium72. Reversible cardiomyopathy attributed to catecholamine.68, 73, 74 Pulmonary edema is due to myocardial dysfunction. However, acute lung injury pattern or adult respiratory distress like syndrome attributed to secretory or non cardiogenic pulmonary edema reported from Brazil.16 Myocardial and lung parenchymal injury is due to raised level of inteleukine6, tumor necrosis factor and kalikrenin and platelets activating factors.

A study of Histopathology showed accumulation of fluid in alveoli and contraction band necrosis in the myocardium and hyaline membrane in the lung in a fatal scorpion sting case.75, 76 The pathophysiology, clinical and histological, pattern is similar to that of patient suffering from pheochromocytoma.42, 77

On the basis of pathophysiology the therapeutic effort should be directed against the clinical manifestations of the over stimulated autonomic nervous system and after effects of excessive catecholamine and correction of hypovolemia.44, 6 6, 78, 79, 80

Management Scorpion sting is un-noticed sudden onset of a accident. Majority of victims are healthier before sting. Sudden onset of myocardial injury with normal size heart and liberated free fatty acids and increased myocardial contraction were digoxin is no more beneficial. 47 While excessive diuretics is hazardous.81 Reduction of preload by applying rotating tourniquet to periphery did help in three out of four victims of severe scorpion sting with pulmonary edema.82

Figure 7:

Figure 8:

Echocardiography changes- showed poor global contractility 12-15 hours after the sting , with low ejection fraction, decreased systolic left ventricular performance, mitral incompetence, abnormal diastolic filling persisted for 5 days to four weeks . Diminished or hypokinetic left ventricular global movement with decreased systolic function was seen in a scintigraphic study . But in the echocardiograph, there was good correlation between clinical improvement and the return of the left ventricular wall motion toward normal 59, 61, 62, 63.

Hemodynamics-It is difficult to perform hemodynamic study in severely ill scorpion sting case. Karnad D.R. from India studied hemodynamic pattern in a patient with Mesobuthus Tamulus envenoming from western Maharashtra India, reported that mild envenomation causes severe vasoconstriction and hypertension while predominant left ventricular dysfunction with normal

40 4141

Alpha blocking properties of chlorpromazine one of the constitutes of lytic cocktail responsible to reduce the fatality in children, however out of 100 children with severe scorpion sting treated with lytic–cocktail. Of which 22 died, according to a report from Pondicherry India. Pethidine and antihistamine (promethazine) enhances the venom toxicity should be avoided in scorpion sting.83 Insulin therapy was advocated by waterman from Trinidad in 1938.84 Inotropic support was needed by patients admitted with scorpion sting in a intensive care unit irrespective of treatment with insulin glucose drip85. Recently Gupta V from India reported hypoglycemia in 30%, pulmonary edema 40% and fatality 35% in victims of scorpion sting given insulin glucose drip, while in prazosin treated group fatality was 6.2%.86 Negative inotropic effects of calcium channel blocker (nifedipine) and beta-blocker enhances myocardial failure.87 Steroids enhance the necrotizing effects of circulating catecholamine should be avoided in scorpion sting victims.88, 89 Antihistamines inhibit calcium dependent potassium channels like that of Scorpion venom action should be avoided.39, 90

In experimental pharmacokinetic studies with radioactively labeled scorpion venom given intravenously, it was observed that the half life of venom distribution and its excretion were 5.6 minutes and 6.4 hours respectively91. Other similar studies using antivenin showed that the half life of distribution was 1-9 hours with the result of these studies it is concluded that antivenin therapy was inefficient because no interaction could occur between scorpion toxin and antitoxin, justified the use of prazosin and dobutamine92. IgG distribution half life was tenfold longer than that of venom which was short (32 min). In comparison to immunoglobulins, venom distributes fast and achieves greater concentration with a shorter time needed to achieve its maximum concentration72. Severe clinical manifestations due to scorpion sting are alleviated in victim if the antivenin is given within one hour after sting93. However delayed administration of scorpion antivenin did not prevent the pulmonary edema 94. All the ten cases had severe cardiovascular manifestations, irrespective of administration of scorpion antivenin of these 5 recovered with prazosin and four required inotropic support and one died, according to a report from western Maharashtra India95. The persistence of signs and symptoms of envenoming after neutralization of circulating venom could be explained by the inability of antivenin to neutralize scorpion toxins bound to their receptors on the sodium channel 96. A number of specific scorpion antivenins are available but their efficacy is uncertain. Ancillary treatment with vasodilators is crucial in severely envenomed patients79. Administration of scorpion antivenin after one hour of sting did not prevent the development of pulmonary edema8, 27 and cerebral edema (Romero NO, Hernandezt JM 2005), cardiac arrest (Dittrich K, Ahmed R, Ahmed QAA 2002).

Captopril angiotrensin converting enzyme inhibitor did help to alleviate the diuretic induced pulmonary edema in Scorpion sting81. Though the result of captopril therapy is similar to other vasodilator, the author reported 5 deaths out of 38 studied cases treated in intensive care unit in tertiary care hospital78.

In a retrospective study of scorpion sting cases Rajasekhar Detal from cardiology department from Andhra Pradesh reported that L-carnitin to reverse myocardial dysfunction following scorpion envenomation especially in patients with hypotension and severe LV dysfunction63.

Aprotinin was advocated in the treatment of pulmonary edema to inhibit the platelets activating factor97. Recent study by Mangano Detal confirmed that aprotinin is not free from toxicity and can result in acute renal failure, strokes and myocardial infarction98. Moreover it is expensive, not easily available and can cause severe anaphylaxis.

Prazosin is post-synaptic alpha blocker. Prazosin reduces preload, left ventricular impendence a without rising heart rate. It reverses the metabolic syndrome evoked due to excessive catecholamine80. Prazosin is a pharmacological and physiological antidote to venom action39, 99. Three victims developed severe pulmonary edema irrespective of 5 ampoules of scorpion antivenin recovered with oral prazosin a recent report from Saudi Arabia 45 similar observations are reported from Tunisia 100. Morbidity and mortality depend upon time lapsed between sting and administration of prazosin, since the advent of prazosin the fatality is reduced to 1% 28.

Massive life threatening pulmonary edema due severe hypertension or delayed reporting of victim to health center or attended doctor failed to administer the prazosin or inadequate dose of prazosin which advocated three hourly intervals or giving excessivee diuretics, IV fluids, atropine, steroids and antihistamines. These cases to be treated with intravenous nitroglycerine or sodium nitroprusside drip. 7-10% pediatrics cases developed marked tachycardia, hypotension with warm extremities called “warm shock” necessitates dobutamine drip27, 48.

Many toxins from scorpion venoms activate sodium channels, thereby enhancing neurotransmitter release. On this basis Fantail etal in experimental study showed beneficial effects of intravenous lignocaine, a sodium channel blocker101.

Seven young patients admitted with history of scorpion sting presented with pulmonary edema was successfully managed with positive pressure ventilation with PEEP, cardiac support with inotropic and fluid balance according to a report from Nepal 102.

4141

Thus management strategy for severe scorpion sting depends upon the understanding of patho-physiology and proper diagnosis of clinical manifestations and their rational and timely interventions with appropriate therapeutic agents.

Scorpion antivenin is available for clinical use. Scorpion venom is a potent neuronal sodium channel activator resulting in transient cholinergic (vomiting, sweating, salivation, priapism, ventricular ectopic and bradycardia) and prolonged sympathetic (hypertension, tacahycardia, cold extremities, pulmonary edema, hypotension, shock or warm extremities with pulmonary edema and deaths) stimulations. On going cholinergic phenomenon suggestive of free circulating scorpion which can be neutralized by anti-venom. While sympathetic stimulation suggest after effects and fatality is due to sympathetic over activities. We treated 20 cases of severe scorpion sting with scorpion anti-venom 30-50 ml and oral prazosin. We found that if victim reported earlier within 1-2 hours of sting the recovery time in a group treated with scorpion antivenin and prazosin is shorter than the cases treated with prazosin alone. Bur the cost of one ampoule of scorpion antivenom is >350 Rs and at times 100 ml (10 Ampoules) of anti-venom is advocated . While one mg prazosin cost is Rs. 32 for ten tablets. Further work is in progress.

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and Benslimane A. . Scorpion envenomation and serotherapy in

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HA. Study of cardiac changes in Egyptian children with scorpion

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2006;6:1033-38.

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in México. Toxicon 1994;32:1015-18.

22-Mazzei de Davila C, Davila DF, Donis DJ et al sympathetic

42 4343

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yellow scorpion Leiurus quinquestriarus. Toxicon;1992;30:765-67

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N. Electrocardigraphic . enzymatic and echocardiographic evidence

of myocardial damage after Tityus serrulatus scorpion poisoning.

Amer.j.cardiol 1991; 67:655-57.

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Chavez Cc. pediatric electrocardiograph abnormalities following

centruoides limpidus tecomanus scor[pion envenoamtion. Toxicon

2004; 1-5

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Prolonged atrio-ventricular block following scorpion bite: a case

report. IJMS .2003;28:96-97.

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cardiomyopathy. Ame. Heart j.1992; 123:725-29.

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Cupo P. reversible cardiomypathy in patients withsevere scorpion

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47

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of cardiovascular manifestations of scorpion envenoming in

humans. J.Trop.med and Hyg. 19992; 95:30-35.

44 4545

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R and Benslimane A. Scorpion envenomation and serotherapy in

Morocco. Am.J.trop. Med.hyg 2000.;62(2):277-83.

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:the Saudi experience with serotherapy. Toxicon 1994;32:1019-26.

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in scorpion sting (2007). http://www.swamisamarth.com

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envenoming and the heart 9 an Indianexperience) Toxicon;

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F. Scorpion sting envem nomation in children in southeast of

Turkey. J.Wildernesss environ, medicine (in Press)

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effects of lignocaine on actions of the venom from the yellow

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38:1767-01.

102-97-Bhadani UK, Tripathi M, Sharma S, Pandey R. scorpion

sting envenomation presenting with pulmonary edema in adults: a

report of seven cases from Nephal. Indian J.Med.Sci.2000; 60:

Search strategy and selection criteria

We are studying and treating scorpion sting cases since 1977 till today.

We have got collection of articles from request reprints obtained

from authors since 1977, before electronic media. Extensive search

made by scorpion sting, pulmonary edema, catecholamine on pub

made and Google

Legends for figures

Fig-1- Black scorpion (Palmaneus gravimanus)

Fig-2 - An Indian red scorpion (mesobuthus tamulus)

Fig-3 – Tented T waves

Fig-4-A Left anterior hemiblock and subsequent development of

left bundle branch block with PQRST alternnan

Fig 4-A recovery of fig 4A case .

Fig-5-Bat wing appearance of pulmonary edema

Fig-6 A – pulmonary edema

Fig 6 B- recovery from pulmonary edema

4545

BOX 1

Scorpion sting

Local pain without systemic involvement is benign.

Vomiting, sweating, salivation, priapism in male, cold extremities suggestive of autonomic storm. Needs close monitoring.

Hypertension, hypotension, bradycardia, tachycardia, ventricular entopic and acute myocardial infarction like pattern seen in ECG.

Pulmonary edema, hypotension and tachycardia with respiratory failure seen within 30 minutes to 10 hours of sting.

Massive life threatening pulmonary edema needs rapid intervention.

Tachycardia >125 per minute with warm extremities, with or without pulmonary edema with cadaver pallor with convulsions suggestive of poor prognosis.

BOX 2

If victim reports within on hour of sting with autonomic storm, if scorpion antivenin is avail-able in dose of 30 to 100 Ml, it is to be administered by intravenous route. After one hour it has negligible action to neutralize the venom. Even after giving antivenin, victim should be closely monitored for possibility of development of pulmonary edema.

Oral parzosin 250 microgram in children below 5 year and 500 microgram above five year to be administered, in every three hour interval till extremities are cold.

Single dose of 20-30 mg frusemide, aminophylline, oxygen, in addition to parzosin to be given to pulmonary edema case.

Intravenous sodium nitroprusside 3-10 microgram/kg /minute or nitroglycerine drip 5 micro-gram per minute raised to 15 microgram per minute in case of massive pulmonary edema.

Dobutamine 5-15 microgram/kg/min in case of warm shock.

BiPaP or non-invasive ventilator is useful for refractory pulmonary edema with respiratory failure.

BOX 3

Repeat xylocaine for local pain to be avoided local pain can be well managed with oral NSAID, Diazepam and local cold therapy.

Atropine, steroids digoxin, antihistamines and excessive diuretic to be avoided.

46 4747

REVIEW ARTICLE

Challenges in EmergencyManagement Research

“EMS research is a work in progress. There are no easy answers

and no easy methodologies – but nothing worthwhile is ever

easy. For some issues, the window of opportunity for necessary

research has closed. On others, the window is closing fast. And

Dr M K Saxena

Abstract:

for some, the window has yet to be built. Our challenge is to intervene on those issues where the window is still open and carefully craft the windows of the future.”

Elizabeth A Criss1

4747

Emergency management is a response to a situation which may rightly be termed as ‘predictable surprise’ which by the very virtue of its nature is unpredictable to the victim, life threatening and largely due to circumstances beyond his control, but contradictory though it may sound, can be predicted by research methodologies. In a large majority of cases, the victim may not be in a position to seek medical treatment. In a number of cases, especially road traffic accidents even the bystanders may be reluctant to take the victim to a medical facility due to medico legal issues, leading to lives lost that can potentially be saved. Evolution of emergency management services is still in its nascent stage. USA made a beginning in 1968 through 911 services. California passed its EMSS act as late as 1973.2 China, the most populous country introduced EMS in 1980, with a predominant urban focus. The ‘Rescue centers’ provide both ambulance and inpatient care.3 Madagascar with a population of 15 million has again an EMS with urban bias.4 Japan has an EMS run by fire defence headquarters and is basically a single tiered system.5 India, the largest democracy, and the second most populous country in the world had its first comprehensive emergency medical services rolling out in 2005, with advent of Emergency Management & Research Institute (EMRI). Israel, a small nation of 7 million population has an EMS service that attends to approx. 1000 calls /day and in addition has mobile teams to be dispatched to scenes of international disasters.6

Indonesia, the fourth populous country in world has an emergency medical services functioning, with only 26 ambulances covering Jakarta, having an area of 661 sq. k.m. and a population of 10-12 million population. The service receives 1500-1800 calls per month.7 When this is compared with 31,526 calls received by EMRI services in one city only i.e Hyderabad for the month of August 08, it shows the extreme of disparity in the number of calls attended. Such a situation when translated into a database is an indicator of challenge posed to EMS research. The challenge increases in magnitude when one considers regional imbalances in terms of illiteracy and poverty causing deficiencies in information given by relatives of victims and competence of paramedics contributing to database inconsistencies.

It is also true, that if decisions in EMS have to be evidence-backed and not based on mere assumptions and hypotheses, it is a must, that research must be incorporated into evaluation of protocols, and procedures. The present challenges relate to systems design,

Author: Dr M K Saxena, M.S, Senior Partner, Applied Research, Emergency Management And Research Institute, Secunderabad, India. e-mail: mukul_saxena@emri.in

uniform evaluations of emergencies and comparing outcomes.Unfortunately, most published research in EMS is component based, focusing on a single intervention or health problem and rarely addressing the inherent complexities of EMS systems1

The design of experimental research under pre-hospital conditions is by itself a major challenge. Biases in emergency service medicine research relates to variability of EMS personnel and their qualification and hence it may not be possible to prove efficacy and efficiency in emergency management practice.8 Hopefully this situation is likely to change with institutes training them on standard curriculum .

Unlike other spheres of clinical research, research in EMS, does not have to follow the animal experiments, and has to make a beginning with retrospective data that is available. The challenges a researcher faces are in data interpretation / validation. As most EM services are oriented towards pre-hospital care, retrospective data is often silent on certain specific aspects such as the diagnosis. Should one consider the diagnosis based on the interpretations of clinical findings by a trained paramedic, or the researcher’s own inclusion and exclusion criteria, or hospital diagnosis obtained subsequently? This in turn brings up the challenge of the issue of confidentiality and right to privacy of individual. The issue of linking with patient outcomes shall depend on certain established information systems within the EM services as well as with the hospitals.

The emergency services do not have the existing research backup so essential to any research field. There is hardly any academic research institution with long term commitment to EMS research. Most of the institutions which do carry out research on EM subjects pertain to the Emergency room admissions and ICU interventions.This is a challenge that EMRI seeks to address. Research in EMS through prospective studies is burdened by restrictive interpretations of informed consent.The ethical issues get more challenging in scenarios that are bound to unfold when EM services are likely to increase their activities covering larger populations and areas where the increased load on emergency services shall lead to triage protocols. Research on pre-hospital interventions also needs to be sensitive to such challenge. The most important challenge stems from the application of basic ethical principles to research in emergency medicine setting involved in resuscitation in vulnerable population.9 A recent Academic Emergency Medicine Consensus

48 4949

Conference on “Ethical conduct of Resuscitation Research” addressed the term applicability of term vulnerable, relationship between vulnerability, exploitability and capacity significance of vulnerability in Research designs, adaptation of informed consent process to emergency setting, and role of institutional review board. One of the consensus recommendation that emerged from the discussion was the endorsement of the idea that research using EFIC (Exception from informed Consent) is as important in vulnerable population as in the general populations and that the systematic exclusion of vulnerable populations from resuscitation research is inappropriate.10

National EMS Research agenda has identified barriers to research as Primary and secondary. The primary barriers include paucity of trained researchers with interest in EMS Research and paucity of funding. Secondary barriers include recognizing the need for EMS Research.11 In the Indian setting, EMRI stands out as an institution to create centre of excellence in EMS Research, and address these challenges.

The researchers around the world have tried to come around to some kind of consensus on certain issues and have identified them as the type of study (System study versus specific intervention), population under study, Physiological and anatomical scoring methods, prospective definitions of interventions and meaningful outcome variables, relative outcome compared to known standards and prospective determination of statistical requirements.12

However, notwithstanding the magnitude of challenges, research in EMS has to break new grounds, come up with solutions that are likely to help the EM Services achieve their objectives in a scientific and cost-effective way and share their experiences and insight with researchers and those who are working in or are associated with EMS through scientific journals. The magnitude of challenges may be high, but so are the expectations from the EM Researchers globally, and bringing out this issue of the journal is a humble but determined step in this direction.

REFERENCES:1. EMS Research: Elizabeth A Criss. Obstacles of past,

opportunities in present, models for the future. http://www.pcrf.mednet.ucla.edu/pcrf/pcrfarticle1.shtml (online ref.)

2. P.L. 93-154; Emergency Medical Services Systems Act of 1973 state of California

3. Emergency Medical Services in China. Thomas TL, Clem KJ.Acad Emerg Med.1999Feb ;6(2) :150-5

4. Profile of the prehospital system in Madagascar. Ramalajaona. Prehosp Emerg care.2001 Jul-Sep ;5 (3) ;317-21

5. Emergency Medical Service Systems in Japan: Past, present and future. Tanigawa K, Tanaka K Resuscitation. 2006 Jun 69(3):365-70

6. The EMS in Israel: Magen David Atom, Resuscitation, volume 76,issue 1,pages 5-10

7. Prehospital care in Indonesia . Pitt E, Pusponegoro A, Emerg Med J 2005 ;22:144-47

8. Emergency Medical Services Systems Research: Problems of past, challenges of the future. Spaite DW, Criss EA, Valenzuela TD, Guisto J. Ann Emerg Med.1995, Aug ;26(2): 146-52

9. Research and ethics in emergency medicine. Findings of a workshop. Dick W, Ahnefield FW, Encke A, SchusterHP ; anaesthetist 1996 May;45(5):413-9

10. Resuscitation Research involving vulnerable populations: Are additional protections needed for emergency exception from the informed consent. Baren JM,Fish SS. Acad Emerg Med.2005 Nov ;12(110:1071-7,

11. NATIONAL EMS RESEARCH AGENDA, Published: December 31, 2001; Available at http://www.nhtsa.dot.gov/people /injury /ems/ems-agenda/EMS Research Agenda pdf (online ref accessed on 26 Oct 2008)

12 Challenges in Prehospital trauma services. Current issues and suggested evaluation tools. Pepe PE, Majo RF, Prehosp Disaster Med .1993 Jan-Mar;8 (1 suppl): 25-34

4949

EVENTS & NEWS

Knowledge shared is Knowledge gained……………

With this belief, Alliances & Partnerships facilitates workshops / conferences on a regular basis, bringing the experts in various fields of Emergency Management and stakeholders on to a common platform.

Year 2008 started with two very interesting conferences.

Geospatial Technology in Emergency Management (GEM) conference, organised on 2nd February 2008, witnessed participation from health, police, disaster management and other organizations such as ISRO, NRSA, ESI, Google, Microsoft etc., which specialize in developing Geospatial technologies.

Speakers were drawn from various industries, who use Geospatial technology in their business (please see photos)

On this occasion, we thought it befitting to recognize some individuals / organisations who have contributed significantly in the Indian scenario for advancing Geospatial Technology. Six Awards in different categories were given to:

• Dr. A.P. Ranga Rao • AP Pollution Control Board

• Prof. I.V. Muralikrishna • Dr. T. Raja Rao

• Mr. P.S. Roy • Dr. P. Subba Rao

Dr.Thomas Krafft, Geomed Research, Germany

Dr.M Anji Reddy, JNTU Prof. I V Muralikrishna, JNTU

Demonstration on Robotic technologyWinners of Student Poster CompetitionPoster Presentation in progress

A Student paper competition was also held to encourage students focussing on this area of technology to showcase their creativity to the experts. The winners were T Balakrishna and P Srinivasa Murthy from Sri Sunflower College of Engineering & Technology

Adopting Military Medicine Best Practices for Civilian Emergency Response – This one day conference was held on 29th February.

Through this conference, EMRI tried to leverage the immense knowledge in the domains of planning, preparedness and delivery of emergency care from the experts of Military Medicine. At the same time, this was a platform for all like-minded individuals to foresee challenges to come and enable innovative solutions to meet them.

With participation from the Indian Armed Forces and various Central and State Governmental Agencies including but not limited to the Defence Research and Development Organisation (DRDO), Police, Fire and Health Care providers, Aviation

Medicine, the Conference created an opportunity for the assembled guests and speakers to debate on issues that can impact the practice of EMS and Military Medicine in the future.

50 5151

The highlight of this conference was a drill by Indian Air Force led by Gp. Capt. Rajesh Isser and his team. The demonstration included Loading of two patients from an Ambulance in to a Medical Evacuation (med vac) Helicopter and Winching (vertical lift) of a patient from an inhospitable terrain.

Inaugural Address was delivered by Lt. Gen. (Retd.) Y N Sharma, PVSM, AVSM, VSM, Former General Officer Commanding in Chief, Ex Colonel The GRENADIERS, while Key Note Address was delivered by Brig. T P Madhusudanan, Commandant & SEMO (AMC), Military Hospital.

Lt. Gen Sharma (center) with Brig. Madhusudhanan (left) and Dr Ramana Rao

Session in progress

Mr. P.S. Roy receiving Lifetime Achievement Award

Brig. Madhusoodhanan (left), Col Masur (center) Col V. N. Jha

Lt. Gen. Y.N. Sharma

xxxxxxDr. Col. Kumud Rai, Max Heart & Vascular Institute, New Delhi

Dr Suresh David, CMC, Vellore

Amit Prasad, SatNav Technologies

Some of the speakers included well known medical professionals in army, airforce and hospitals, like Col. Dr Kumud Rai, VSM; Dr Suresh David; Col. CVR Mohan ; Col. MM Masur; Gp. Capt. Rajesh Isser; Mr Pete Collins, City of Austin, USA.

Alliances & Partnerships is working on bringing many more such programmes of this nature which will held in improved emergency management while enhancing the knowledge and skill of those in this field of work. This is also the best way to be in touch with like minded individuals / organisations and benefit from mutual learning

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Invitation for Submission of Manuscripts for Indian Emergency Journal (IEJ)

• Original Research Articles in Emergency Medicine, Emergency Management practices, Applied Research studies, Critical Review on major issues, and Government Policies influencing all facets of managing emergencies

• Article should not exceed 6,000 words

• Review articles should not exceed 8,000 words

• Short reports should not exceed 2,500 words

For any clarifications, please contact the Managing Editor at:Editor, Indian Emergency Journal,Emergency Management and Research InstituteDevar Yamzal, Medchal Road, Secunderabad - 500 014.Ph: 91-40-23462222 / 2200, Fax: 91-40-23462178email: editor@emri.in

Website: www.emri.in

The Editorial Board of IEJ (also the Research Forum of EMRI) is

pleased to announce that the publication of next quarterly issue of

Indian Emergency Journal.

EMRI (Emergency Management and Research Institute) is a

pioneer in Emergency Management Services in India. It is a not- for

- profit professional organization founded, funded and nurtured by

Mr.B.Ramalinga Raju, Founder and Chairman, Satyam Computers

and his brothers. Operating in the Public Private Partnership (PPP)

mode, EMRI is the only professional Emergency Service Provider

in India today.

Published from EMRI, Indian Emergency Journal is an applied,

internationally oriented Emergency management journal designed

to help practitioners and researchers stay abreast of the latest

developments in the emergency management field, as well as,

facilitate the exchange of ideas.

The journal would allow those with research and management

interests in the field of emergency, a global, multi-disciplinary

forum for the dissemination and discussion of research, and to keep

abreast of the latest developments in the field. Research articles and

critical reviews in the journal will provide a significant coverage

of emergency medicine, emergency management practices, applied

research studies, critical reviews on major issues, and government

policies influencing all facets of managing emergencies.

Original research articles, review articles and short reports with

the above subjects are considered for publication in the Journal.

In principle, an original research article should not exceed 6,000

words, including all illustrations and references. Review articles

should not generally exceed 8,000 words and short reports also

should not exceed 2,500 words.

Original research articles, review articles and short reports with the

above subjects are Manuscripts, alongwith a cover letter, should be

sent to the Editorial office in Hyderabad in electronic format to:

editor@emri.in. Three print copies of the manuscript may also

be sent by post to: Managing Editor, Indian Emergency Journal,

Emergency Management and Research Institute, Devar Yamzal,

Medchal Road, Secunderabad-500014, Andhra Pradesh.

While preparing manuscripts, please follow the Vancouver Style

(Uniform requirements for manuscripts submitted to biomedical

journals prepared by the International Committee of Medical

Journal Editors, which is available at http://www.icmje.org

52 PB

Emergency Management and Research InstituteDevar Yamzal, Medchal Road, Secunderabad - 500 014, Andhra Pradesh, India.

Ph: +91-40-23462600, 23462602, 23462222 Fax: +91-40-23462178