Kumar Sandeep, Chaudhary Sushant, Kumar Akshay, Agarwal Arpit Kumar, Misra M C
Department of Surgery, King George's Medical University, Lucknow, 226 003 UP India.
Indian J Surg. 2009 Jun;71(3):133-41. doi: 10.1007/s12262-009-0037-0. Epub 2009 Jun 10.
Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years.
To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India - Delhi (2 centres), Lucknow and Mumbai.
Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers.
Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables.
Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning - anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute.
Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended.
在印度，急症服务方面训练有素的医生和辅助医务人员匮乏。作为印度医学委员会认可的专科，创伤与急诊医疗系统（EMS）的教学与培训尚未作为研究生医学教育项目开展。印度军队和民用医院的医疗主管（MI）和伤亡医疗官（CMO）办公室负责进行伤情分类、急救、法医学手续、转诊并安排患者转送至各科室，这导致了不必要的延误，且缺乏多学科方法。在过去几年里，仅在印度的少数几个城市建立了综合创伤与急救基础设施，农村地区则没有。
研究印度三个首都城市——德里（两个中心）、勒克瑙和孟买已设立的创伤中心的基础设施、人力资源配置、运作情况、未来计划及愿景。
通过对上述创伤中心的设施和运作情况进行为期7天的直接观察，开展参与观察式结构化开放式定性研究。
记录以下方面的信息：1. 基础设施；空间与建筑、手术室、呼吸机、诊断及血库设施、财务与成本以及院前护理基础设施；2. 人力资源；顾问医生和住院医生、辅助医务人员及专家；3. 工作方式；第一响应者、接收的患者类型、烧伤管理、手术管理及转诊系统、后续患者管理、社会支持、丧亲服务及尸检服务，通过使用预先构建的开放式工具对官员、工作人员进行访谈并直接观察来记录数据。数据进行压缩处理，按照定性研究方法进行同行分析，并以清晰的表格形式呈现。
德里、马哈拉施特拉邦和北方邦的联邦及邦政府已投入大量资金在其首府城市创建创伤与急救基础设施。多数情况下，由普通外科医生和骨科医生及其住院 staff 管理这些设施。所有中心均未配备经过全面培训的急症（AandE）人员。偶尔能获得心脏骤停周围心律失常、外周及微血管修复的专家管理。颌面、牙科和口腔修复设施、中毒分级及中毒治疗——抗蛇毒血清未整合。所有4个中心均有呼吸机、麻醉师、神经外科医生和整形外科医生随时待命提供紧急护理。所有4个中心均具备急诊诊断放射学（X 光、CT 扫描和超声）及病理学检查。仅德里的中心设有现场血库和成分输血治疗。尽管官员们有此设想，但院前护理缺乏。没有经过全面培训的高级 A 和 E 人员作为第一响应者。未见到针对烧伤患者的双重屏障护理。腹腔镜和纤维内镜急诊手术也仅在德里才有。未发现因法医学手续不完整导致的治疗延误。普遍缺乏社会和法律援助、丧亲服务及尸体冷藏室。德里为贫困和赤贫者提供免费治疗，勒克瑙提供部分经济支持。
尽管起步较晚，但创伤服务已有所发展，德里和勒克瑙已建立了庞大的创伤基础设施。必须强制要求在创伤与 EMS 方面进行研究生认证，并制定国家伤害控制计划，以改善印度的创伤护理。建议整合医疗、非创伤性外科和儿科急诊以及院前护理。
