India is the second most populous country in the world and will soon overtake China in being ‘numero uno’. There is a growing disparity between the numbers of patients per doctor. In such an atmosphere, Emergency Physicians are a growing need.
In 1999, the Society of Emergency Medicine, India was constructed with aim to promote emergency medicine in India.1 In its first ever meeting held in 1999, it brought together Emergency Medicine (EM) enthusiasts to build the field. Since 1999, doctors interested in the field undertook 6 months to 2 years of diploma/fellowship courses by working in a ‘casualty’, to become ‘Emergency Physicians’. It was in 2008, when a white paper was published on Academic Emergency Medicine in India by the INDO-US Joint Working Group, that things started rolling. This paper put forward a standardized curriculum for EM in India.2 Finally, after 10 years, on 21st July 2009; EM was officially recognized as a branch of medicine by the Medical Council of India.3
Concept of “Casualty”
Casualty departments are prevalent in most hospitals in India. Casualty is a 4-5 bed set up, with 1-2 nursing staff, a helper and a doctor. The doctor, mostly a resident or intern evaluates the patient and calls what they determine is the relevant specialty to take over the case. The job of ‘casualty medical officer’ includes, but is not limited to primary evaluation, first aid and calling the specialist. He/she may not always have training in EM. The department may also lack all the necessary resuscitation equipment.
Emergency Medicine – an emerging branch
Emergency Departments (EDs) are being developed by corporate hospitals and are flourishing. This growth is restricted to corporate hospitals which cater mostly to middle and upper class patients (i.e. the economically well-off). Patients from low income groups cannot afford the costs of investigations and treatment so a vast chunk of patients do not benefit from the EDs in corporate hospitals.
I hope for seeing ‘casualty’ in government hospitals converted to ‘emergency department’.
What we do in our ED?
I work in a level one comprehensive trauma centre; one of the very few in western India. It is comprised of 18-bed Accident & Emergency Department which is equipped with state-of-the-art equipment for a wide spectrum of patients with acute emergencies. It is divided into triage area, an acute care unit, a minor operation theatre, isolation room and a resuscitation bay.
We triage, evaluate, stabilise, diagnose and disposition the patient. We adhere to evidence based guidelines, have excellent door to needle & door to balloon time (75% of MI patients undergo thrombolysis within 30 minutes). We use MRI scans for suspected stroke and have superb thrombolysis time (70% within 60 minutes of arrival) and great outcomes. We work with orthopedic surgeons and neurosurgeons as a team for treating trauma victims. We have started using Ultrasound for FAST scan, RUSH exam and interventional procedures like central line placement. We also go on ambulance calls and perform out of hospital resuscitation. We are taught EM by the finest of emergency physicians across the world.
I dream that every emergency department get well trained and well qualified Emergency Physicians.
Academic emergency medicine in India
Residency training programs in EM are carried out under different banners. The MD (Post-graduate degree) and DNB (Diplomate of National Board) post-graduate programs hosts EM across a few hospitals in India. The number of seats are insufficient. These are recognised by the Medical Council of India. Then, there are three year training programs like the Masters in Emergency Medicine – International program which is affiliated with George Washington University. It is a structured program with equal weight to academics, clinical skills and research. EM faculty from USA, UK, Australia, Singapore and India with vast experience and knowledge train the residents to grow into qualified Emergency Physicians. A similar program has been carried out by Society of Emergency Medicine, India called Masters in Emergency Medicine (SEMI). Apart from these major three year programs, there are minor- one to two year diplomas and fellowships in EM awarded by local universities. The biggest challenge faced is lack of EM trained faculty. Hence, at some courses there is ‘self-learning’ or teaching by a specialist who isn’t an Emergency Physician.
I wish that Emergency Physicians across the world would strive for the growth of International EM, by coming over to teach the future Emergency Physicians of India.
With various courses under different affiliations, there is discord for recognition. There needs to be a centralised exam similar to the American Board exams for all the residents completing their respective courses to streamline this field.
Stress has to be laid on research. With such a huge patient population, studies need to be conducted in order to practice true evidence based medicine. Not all western studies can be translated in Indian scenario considering the different disease cohort, costs and availability of resources.
Doctors, as well as lay public, need to recognise this field. The presence of multiple specialists have given rise to a ‘consultant culture’. Many consultants fail to recognise EM as a specialty. Patients feel the ED is a place where they will be promptly looked after for the minutest of the complaint; a way to bypass the out-patient department. They need to be educated about the role of EM.
The number of Emergency Physicians generated per year are inadequate to staff EDs across India. Most of them pursue dream of furthering their career by moving to the UK or Middle East.
Development of EM in India bears significant resemblance to that in the USA albeit with plenty of novel challenges. It has been 7 years since recognition and the field is still crawling along. We have a long way to go to become a well-recognised, sought-after medical branch in India.
Nikhil Tambe is an Emergency Medicine enthusiast, a lifelong learner, a proponent of Evidence Based Medicine, loves ECGs, resuscitation and emergency cardiology. He has always been actively involved in teaching basic and advanced lifesaving skills to medics, paramedics and lay public since 2012. Currently he is pursuing EM Residency at Kokilaben Dhirubhai Ambani Hospital under George Washington University – Masters in Emergency Medicine Program. His vision is to create awareness about EBM and develop EM as a stand alone speciality in India.
- Das, A. K., et al. “White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG).” JAPI 56 (2008): 789-797.