Chapter

Prehospital Care for Orthopedic

Trauma: The Asian Perspective

4
2000-2010, was declared the Bone and Joint decade. The
Chairman of World Health Organization mentioned that
Trauma care would probably become the 3rd largest
economic burden to the nations with a high incidence of
mortality and morbidity in the years to come. There is no
estimate of man-hours lost. To consider the Asian perspective
of prehospital care, the point to be considered is Does the
trauma care involve only reduction of mortality, morbidity
and prevention of disability? It needs to be understood
that for any system to achieve its goals, it cannot be
considered in isolation, and must be a part of a very wellformulated policy. Going through the literature, the Asian
perspective appears to lay more stress on the epidemiology
and existing trauma care systems and protocols which differ
with each nation and policy makers. In each state as a
result there is no consensus on the operational part of prehospital care.
A report on Road Traffic injuries prevention (BJD
2000-2010) in European Musculo Skeletal review,
mentions about, the interest the United Nations has laid
on this issue, and also pointed out serious lacunae in
prehospital care in Asian countries. In India, there have
been no efforts to organize the prehospital care in the past.
Ideal would be to have prearranged emergency services
everywhere. In short, India requires a better Emergency
Medical Services, to meet the growing number of
emergencies. What currently exists, is in the form of
fragmented services across the country, which falls short
of meeting the requirements. Whatever, terminology may

Nandkishore Shamrao Laud

be in use like Golden Hour, Platinum 10 minutes,

the vital aspect of emergency care (especially prehospital),
is to create an environment and facilities where the injured
or diseased can get emergency care on the spot with medical
support and can be transported to the nearest available
medical center with proper EMS care (P Potluri).
In India majority of institutions unfortunately continue
to follow the concept of casualty, which universally is not
an accepted norm. It is thus essential that the concept of
casualty needs to be changed to Emergency Medical Services,
alternatively Accident and Emergency Services (like in USA).
In the Western world, there are national policies which
need to be implemented by each state, and cover
resuscitation, medical care during transportation along with
communication to the trauma center. The national training
programs have been standardized for trauma and cardiac
care (ATLS and ACLS).
It is also observed that adequate and planned prehospital
care not only leads to reduced mortality but affects morbidity
profile. Just providing financial support or creating newer
technologies has not yielded the desired results, especially
in developing countries. The developed nations are also in
the process of re-evaluating the merits of the existing system
especially of air transport.
While transportation is an integral part of first aid, it is
not the only modality which determines the final outcome
and progress.
The management of trainees is an ever increasing
challenge, a difficult task needing continuous monitoring,

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First Aid and Emergency Management in Orthopedic Injuries

analysis, documentation and research. Prehospital care being

an integral part, cannot be performed or developed in
isolation.
Till the late 1970s or early 1980s, the concept of prehospital care was nonexistent in India and in other countries
in the Asian region, especially SAARC nations. The first
dedicated Intensive care ward was established in LTMG
Hospital, Mumbai, Maharashtra, India, in 1974. Though
this was the initial effort to prevent death, an effort was also
made to support it with dedicated Trauma van, with facilities
for on the spot resuscitation by equipping the Ambulance
with Life Support systems, a trained nurse and, a doctor
with two transportation assistants. However, in the long
run it was not found to be a workable solution, since the
hospital was located in the city and accidents took place at
the periphery. Often traffic delay led to deterioration in the
condition of the victim. In 1986-87, Golden Hour Project
was initiated with trauma vans inaugurated at the hands of
Shri Rajiv Gandhi, our late Prime Minister. Unfortunately,
this was an effort aimed only at transportation without any
communication or treatment facilities. Even the personnel
manning the ambulance had no knowledge about the
importance of resuscitation. Though it was started as a free
service, it did not become viable.
To rationalize prehospital trauma care in India, a two
day national convention on Prehospital care was held on
26-27 October 2006, at the National Institution of Health
and Family Welfare, New Delhi. The experts deliberated
on the issues. The committee studied the available models
and their impact on the current status of trauma
management. Assessing each model and its merit, it did make
some impact on the current prehospital care. The workable
models have been:
1. Centralized Accident and Trauma Services (CATS),
Govt. of Delhi: CATS is an autonomous body under the
Government of Delhi, started in 1991. Primary
objectives of CATS are:
i. To reach the site of accident as quickly as possible.
ii. Give first aid to the patient.
iii. Quick and safe transportation of the patient to the
hospital.
iv. To liaise with other organizations such as Delhi
Police, Delhi Fire Service and any other government
agencies for the benefit and care of the accident
victims.

v. To man the ambulances with trained personnel.

vi. To initiate training programs to fulfill the basic needs
of prehospital care.
This was started in 1991; it was the first time that the
objectives were specified.
In Mumbai, ambulance services known as AAA
(Ambulance Access for All) was started as a nonprofit
organization. The facility lays stress on acute life support
system and treatment during transportation. Encouraged
by its performance, the state of Kerala initiated the same in
their state.
In Northern India, CMC Ludhiana, Punjab initiated a
concept of Ambulance Motorbike and Rescue Service
(AMARS) in March 2003. The idea was to reach injury/
accident victims who may be on narrow lanes and roads
where standard ambulance may not reach in time.
In Tamil Nadu, Emergency and Accident Relief Center
(EARC) is a project by the Indian Medical Association with
Government of Tamil Nadu for providing emergency care
to road traffic accident victims. The principle was the same,
common toll free number, location at the accident site, quick
contact facility and transportation to the nearest treatment
center. The committee also gave recommendations on the
various aspects to ensure the plan involves the entire part of
the country from PHC level to the urban superspecialty
centers. It also laid stress on the need for manpower training
and skills to be learned in a stagewise manner from the
volunteer forces to the advanced trauma treatment. The
hallmark of this report is the specifics of services provided
by communication, ambulance, personnel, hospital
preparedness, triaging, rehab services, data recording and
management.

AIM
To reduce mortality
z
To reduce morbidity
z
To prevent disabilitytemporary/permanent
z
Ensure early quick recovery
z
Restore preinjury status as and when possible.
Today, in developed nations, majority of the lives likely
to be lost on the road can be salvaged and those severely
injured, can be restored to as near normal as possible. To
achieve this, what the state and the nation needs, is to
understand the genesis of its occurrence, systematic analysis
z

Prehospital Care for Orthopedic Trauma: The Asian Perspective

of the problems involved, and systems approach in

management of trauma care.
The prehospital care plan should be based on the
following basic issues with each component given its
responsibility with dedicated personnel to fulfill needs of
trauma victims. The proposed plan has to have a toll free
nationalized number, for example, 102. It should be a
standard for all of the states covering the entire population
and road network. It should be interconnected with communication systems (Flow chart 4.1).
The essentials for prehospital care are described in Flow
chart 4.2.

25

(crash trolley) splints, special stretchers, spine boards, cervical

collars and proper dressing material, etc. The aim is to
prevent further trauma and blood loss in open wounds by
adequate and proper dressing and bandaging. No effort is
to be made to offer any definitive care. The aim is quick
salvage and to prevent further trauma.
Personnel

Wherein the accident victim or a passerby can immediately

contact the nearest Police station or Fire brigade. The facility
should be such that these are connected by a telephone or
an Alarm system. The importance of first contact with the
Police personnel is to reach the spot and clear the roads,
especially in urban areas for Ambulance to arrive quickly
and isolate the area, so that the trained medical professionals
from the Ambulance services should carry out their work
uninterrupted. In case of vehicular crashes, building collapse
and disaster areas, floods, etc. the prehospital policy must
involve the Fire brigade since rescue from the damaged
vehicles or wall collapse become an essential issue. Hence,
the alarm should also be at the nearest Fire brigade site
especially in districts and urban centers. The Ambulance
services should not be a part of common services pool which
is at present the policy in our country.

Ideal will be to have two well trained paramedics with

adequate training in resuscitation, maintenance of airway,
breathing and circulation, with use of splinting for skeletal
trauma. They should have training, be skilled drivers and
have the ability to communicate during transportation. A
protocol management sheet is essential, wherein the
recording becomes simple, quick and informative. The
responsibility of this unit of prehospital care is to ensure
that the priority laid down is followed. India today is sitting
on a volcano; disasters manmade and natural are a way of
life. It is mandatory that the citizen volunteer cadres can be
a part of prehospital care. During the Second World War,
many of the family physicians and dispensaries were
designated as air raid posts (ARPs). Similarly, the NRI
organizations and family physicians, nursing homes, can be
an important link between the main hospitals and the
prehospital unit to help to tide over the crisis. The Committees
recommendations lay stress on the importance of personnel
training and since the magnitude of trauma is on the rise and
its pattern is repeatedly changing, it is essential that the
prehospital care should be closely linked with hospital care
with proper recording, data processing and statistical analysis
to modify and plan changes in trauma management.

Rescue, Transportation

CONCEPT OF PREHOSPITAL CARE

In our opinion, the Trauma ambulance should have a specific

color especially yellow so that it could be spotted from a
distance during the day. It must have two bands red and
blue and a different siren and search light blue or orange.
The aim is that the general public can immediately identify
this as a Trauma Ambulance and clear the way for the vehicle
to pass. The design of the vehicle should be such that it is
capable of running at a speed, with independent suspension,
a short radius for turning and which can be easily be
negotiated on narrow roads. At present the majority of
Ambulance services are not capable of high speed and do
not have the requisite suspension and shock absorbing
systems for the comfort of the patients. Air conditioning is
mandatory. The equipment must have life saving drugs,

Trauma care in isolation is not cost-effective. It should be a

part of emergency care services. It should cater to trauma,
cardiac, medical, surgical and pediatric care.
Since the basic management of any emergency care is the
treatment of shock, maintenance of airway and circulation,
it would be ideal to initiate the new system of emergency care
with change in existing casualty concept. Basically our casualty
system is sorting out area with referral. The concept of EMS
would be to create facility with observation beds to have it
basically as treatment center and then referral with the
treatment to various areas for definitive care. Since EMS service
is 24 hours, it should have an adequate area allotted with
observation beds, Emergency theater, basics of diagnosis like
X-ray, USG and availability of blood.

Contact

26

First Aid and Emergency Management in Orthopedic Injuries

Emergency care must be an integral part of medical syllabus.

Every graduate at the end of his training needs to be trained for
emergency care. Internship and part of postgraduate training
posting in EMS for short-term be mandatory.

Efficient prehospital care for trauma consists of

transfer of seriously ill patients to the intensive care
areas and patients who require indoor care to the
specific wards.

Flow chart 4.1: Proposed Plan Accident Emergency Service (NAEMS)

Prehospital Care for Orthopedic Trauma: The Asian Perspective

What is NAEMS?

For NAEMS, it should have clear cut division with specialty

in records, actions, documentation and responsibility.

27

Prehospital care should involve an excellent transportation system using ambulance with specific color codes
and sirens.

Identification
Ambulance
A Grade

B Grade

Color code
Yellow with 3 bands
Cardiac monitoring +
ICCU staff
Yellow with 2 bands

C Grade

White

Facility
Advanced life support

Location
Medical college ICCU Dept

Basic life support

Resuscitation, Wound
care + splints
Two way radio communication
Core transport routine
Routine cases

Accident prone areas

City highways
First aid points
Hospitals, NGOs
Social organizations

A Advanced center
B Base center
C Core center
The city hospitals need to be categorized in the groups
A, B, C. A level centerMedical colleges and institutions
with availability of intensive and specialty backup. B level
centerThe middle size hospitals with availability of
intensive care and life saving surgery. C level center
Peripheral hospitals with facility of resuscitation to be
identified as C level centers. One could easily achieve coordination between A-B-C by specific information. Such a
situation would offer an option to a paramedic to take the
patient to the right hospital in right time.

To organize NAEMS, we do not need World Bank or

IMF loan. All that we need is to change the working
environment, optimize the available space, personnel and
time, leading to efficient financial management of hospitals.
For a Trauma Victim

It is not the Life, but the Quality of Life.

It is not the Function but the Quality of Function that
Matters.

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First Aid and Emergency Management in Orthopedic Injuries

PREHOSPITAL CARE
Flow chart 4.2: Essentials for prehospital care

FURTHER READING
1. Government of Delhi. Evaluation Unit, Planning Department.
Report of evaluation study on CATS 2001.
2. Joshipura MK, Mock C, Goosen J, Peden M. Essential trauma
care: strengthening trauma systems around the world. Injury
2004;35:841-5.
3. Mock CN, Jurkovich GJ, nii-Amon-Kotei D, Arreola-Risa
C, Maier RV. Trauma mortality patterns in three nations at
different economic levels: Implications for global trauma
system development. J Trauma 1998;44:804-14.

4. Suresh DS. Trauma systems in Indiathe CMC Vellore

Experience. Evaluation Unit, Planning Department. Report
of evaluation study on CATS 2001.
5. Wegman Fred. Road accidents worldwide a problem that can
be tackled successfully! AIPCR Publication No. 13.01.B,
1996.
6. WHO South East Asia Regional Office, SCN Department,
New DelhiDisability, ViolenceInjury, Prevention and
Rehabilitation. Newsletter 2001 Vol. 2 No. 1.