India

STANFORD ESSENTIAL PREHOSPITAL CARE REFRESHER TRAINING COURSE
(2013 - PRESENT)

Since it’s inception in 2005, GVK EMRI’s ambulance service has grown into the world’s largest EMS system. In 2014, GVK EMRI provided rapid medical care and emergency transport to nearly 700 million people in 17 Indian states and union territories. Over the past 8 years, GVK-EMRI has provided specialized training to over 10,000 EMT’s, who provide care to an average of 22,000 patients in India every day. Once they are assigned to the field, these EMTs have the opportunity to apply their theoretical knowledge and gain practical experience through each patient encounter. However, ensuring that the EMTs retain core knowledge and procedural competency in a rapidly growing and geographically diverse group can be challenging. 

In order to bridge this gap, Stanford Emergency Medicine International (SEMI) has been tasked with developing a series of focused EMT refresher training modules. The goal of this focused educational intervention will be to provide a simplified, practical approach to the most common and critical presentations faced by EMTs in Indian setting. 

The Essential Prehospital Care Refresher Training Course comprises five different modules: Fundamental Emergency Care, Medical Emergencies, Obstetric Emergencies, Pediatric Emergencies and Traumatic Emergencies.

Each two-day training module will be made up of a series of short topic lectures and interactive, hands-on practical sessions. The brief lecture series will cover only what an EMT really needs to know and focus on practical aspects of recognizing ill patients and the provision of immediate, life-saving interventions (Figure 1). The hands-on sessions will reinforce the lecture content, creating a context for applying knowledge and skills in a mentored environment (Figure 2).

09:00 PRE-TEST
09:30 EMS ROLES & RESPONSIBILITY (OVERVIEW)
09:45 ROUTINE MEDICAL/TRAUMA MANAGEMENT (OVERVIEW)
10:00 PRE-ARRIVAL PREPARATION
10:15 SCENE-SIZE UP
10:30 INITIAL ASSESSMENT
10:45 GENERAL IMPRESSION
11:00 POSITION PATIENT
11:15 TEA BREAK
11:30 CIRCULATION
11:45 AIRWAY
12:00 BREATHING
12:15 EXTREMITY HEMORRHAGE CONTROL (PROCEDURE)
12:30 CPR (PROCEDURE)
12:45 AED (PROCEDURE)
01:00 LUNCH
02:00 SUCTIONING (PROCEDURE)
02:15 MANUAL AIRWAY MANEUVERS (PROCEDURE)
02:30 OPA/NPA (PROCEDURE)
02:45 VENTILATION (PROCEDURE)
03:00 TEA BREAK
03:15 PROCEDURE PRACTICE (HANDS-ON)
04:15 RAPID MEDICAL/TRAUMA EXAM
04:30 BASELINE VITAL SIGNS
04:45 DAY 1 OVERVIEW

Figure 1: Essential Prehospital Care Course (Fundamental Emergency Care), Day 1

As of January 2015, SEMI has rolled out the first three modules (Fundamental Emergency Care, Medical Emergencies, Obstetric Emergencies) with plans to debut the Pediatrics and Trauma modules in late 2015 and 2016. Preliminary testing and data analysis suggests that these inaugural programs have been very effective in addressing the educational deficiencies of practicing EMTs. In order to reach more providers who work all across the country of India, SEMI plans to study a number of novel approaches to disseminating such life-saving information, including video-based and web-based training platforms.

Figure 2: Dr. Peter Acker conducting a hands-on educational session on tourniquet placement

 

 

 

GVK EMRI Research Institute
(2008 - PRESENT)

Faculty, fellows, emergency medicine residents and medical students from Stanford School of Medicine and GVK EMRI have jointly conducted a series of prospective research studies analyzing the epidemiology and outcomes of prehospital patients (with various presenting medical complaints) utilizing a new research methodology known as Online Medical Research (OLMR). OLMR data collection specialists gather real-time demographic and clinical information from EMTs in the field and follow-up information from patients, their family, or their caregivers. To date, we have conducted OLMR studies on the following emergency chief complaints: obstetric emergencies, chest pain, vehicular trauma, GI emergencies, seizures, poisoning/suicide, burns, shortness of breath and non-vehicular trauma. To date, we have enrolled over 7000 GVK EMRI patients in OLMR protocols. These novel epidemiologic studies describe important considerations in patients requiring prehospital emergency care in India. Our initial research goals were to define the population of patients who call for emergency medical service and identify risk factors for morbidity and mortality. Future research will assess the impact of changes or advances in the delivery of prehospital care (e.g., introduction of EMS protocols) in India. This valuable data will help guide healthcare development and resource utilization, preventative public heath measures, and EMS expansion in India.

 

 

 

GVK EMRI Pediatric District Hospital Training Program
(2012 - 2015)

Faculty and fellows from Stanford University School of Medicine were responsible for development and deployment of the Pediatric District Hospital Physician Training Program (PDHPT). The PDHPT is an intensive 3-day course created by internationally recognized educators to address the educational deficiencies of physicians practicing in India. The course addresses a wide range of clinical topics essential to the practice of emergency medicine, and emphasizes a methodical approach to emergency pediatric patient evaluation and management. Each PDHPT course is customizable to the specific instructional needs of the participants and features high quality PowerPoint presentations, hands-on skills workshops, interactive case-based discussions, and a detailed syllabus with color images, practical illustrations and methodical tables.

 

 

 

GVK EMRI District Hospital Training Program
(2009 - 2014)

Faculty and fellows from Stanford University School of Medicine were responsible for development and deployment of the District Hospital Physician Training Program (DHPT). The DHPT is an intensive 5-day course created by internationally recognized educators to address the educational deficiencies of physicians practicing in India. The course addresses a wide range of clinical topics essential to the practice of emergency medicine, and emphasizes a methodical approach to emergency patient evaluation and management. Each DHPT course is customizable to the specific instructional needs of the participants and features high quality PowerPoint presentations, hands-on skills workshops, interactive case-based discussions, and a detailed syllabus (200 pages) with color images, practical illustrations and methodical tables.

 

 

 

GVK EMRI EMS PROTOCOL MANUAL
(2010 - 2013)

Faculty and fellows from Stanford University School of Medicine were responsible for development of Prehospital Emergency Care Protocols, India’s first guidelines for the delivery of prehospital care. The development and implementation of EMS protocol standards facilitate the uniform treatment of injuries and illnesses such that all patients receive the current standard of medical care at the most appropriate location. Results from Online Medical Research demonstrated significant opportunities to improve the care of common emergencies and highlighted the critical importance of utilizing international quality protocols developed specifically for India. Prior to March 2011, these protocols were non-existent or insufficient in quality. Experts from Stanford University School of Medicine have developed 53 EMS protocols for GVK EMRI for use by physicians, EMTs and educators.

These EMS medical protocols (practice guidelines) will provide the highest quality patient care, ensure countrywide uniformity and consistency of prehospital care, and promote current evidence-based practice related to EMS (when this evidence is available). These EMS protocols will also account for and accommodate regional medical practices and medications, and language and cultural issues.

 

 

 

GVK EMRI ASSESSMENT OF EMT-BASIC SKILLS AND KNOWLEDGE
(2013)

Emergency medicine is part of the “10/90 gap in health research whereby less than 10% of global research investment is spent on problems affecting 90% of the world’s population.” The non-profit GVK Emergency Management and Research Institute (EMRI), India’s first centralized emergency medical services with a single telephone number (1-0-8), started in 2005 to address this global issue. GVK EMRI now operates in 13 states in India, serves over 700 million people, deploys over 5000 ambulances, and handles over 15000 emergencies per day.

GVK EMRI’s training institute, the Emergency Medicine Learning Centre (EMLC), has conducted training programs for a variety of levels of EM responders, including a six-week basic EMT course and induction program for the 10,000+ EMT responders who provide the vast majority of GVK EMRI’s prehospital medical care across India.

A key to the successful provision of prehospital care in India is the ability of the EMTs to recognize emergency conditions and provide life-saving treatment. During the summer of 2013, Stanford Emergency Medicine International conducted a study to assess the competency of practicing EMTs (who has successfully completed the basic EMT course). Prior to this study, the knowledge and skill levels of these EMTs had never been formally evaluated.

We assessed the knowledge and skills of EMTs in three Indian states served by GVK EMRI: Karnataka, Tamil Nadu, and Gujarat. We provided a snapshot of the current skill level of Indian EMTs to characterize the key gaps in EMT training, stratified by region, rural vs. urban practice setting, age, gender, years of training, and total number of patients treated. We administered written exams to assess theoretical knowledge and Objectively Structured Clinical Exams (OSCE) to assess practical knowledge.

The study has identified several clinical arenas where EMTs have room for improvement. The study results will be utilized to guide the development of standardized multimedia educational modules and practical hand-on training programs for these EMTs. Following enrollment of all 10000+ GVK EMRI EMTs in this directed educational curriculum, we will assess their progress and formally quantify any improvement. The broader scope of our work is to help India and other nations with similar health challenges design their pre-hospital care curriculum and focus their training appropriately.

 

 

 

GVK EMRI POST-GRADUATE PROGRAM IN EMERGENCY CARE
(2007 - 2009)

Development of a Self-Sustaining Paramedic Educational Program in India: The Stanford-EMRI Partnership

On May 9th 2007, Stanford University School of Medicine Dean, Philip Pizzo, and Emergency Management and Research Institute (EMRI) CEO, Venkat Changavalli, signed a Memorandum of Understanding to develop India’s first collaborative two-year paramedic program (Figure 1), to be taught at EMRI’s campus in Hyderabad, Andhra Pradesh.

The goals of the program were four-fold: (1) train Indian paramedics; (2) train Indian paramedic instructors; (3) train each to international standards; and, (4) develop a world-class Indian training facility.

The Chinese have a proverb, ”Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” With this in mind, this novel program aimed to educate paramedic students while simultaneously training paramedic instructors, thereby ensuring future sustainability.

Figure 1: Dean Philip Pizzo and Venkat Changavalli sign the MOU
in the presence of former AP Chief Minister Y.S. Rajasekhara Reddy

The Post-Graduate Program in Emergency Care (PGPEC), India’s first internationally affiliated paramedic program, was inaugurated on July 15th, 2007. 128 students and 24 paramedic instructor-trainees were initially selected for the PGPEC (Figure 2).

The PGPEC students were all B.Sc. graduates who were selected on the basis of an English proficiency test, physical fitness evaluation and personal interview. Of the PGPEC students, 126 were from Andhra Pradesh and two from Uttar Pradesh. The paramedic instructor-trainees were selected on the basis of their prior expertise in prehospital care and a personal interview. The paramedic-instructor trainees were known as Advanced Clinical Educators (ACEs) (Figure 3). The inaugural group of ACEs was made up of allopathic physicians, homeopathic doctors and EMTs.

Figure 2: PGPEC Students and Advanced Clinical Educators

Figure 3: Advanced Clinical Educators (ACEs)

The PGPEC curriculum was jointly developed by Stanford School of Medicine and EMRI. The curriculum was based on the United States EMT-Paramedic (EMT-P) National Standard Curriculum; however, it included diseases, conditions and cultural issues relevant to the practice of prehospital care in India. The curriculum emphasized uniquely Indian prehospital emergencies such as snakebites, organophosphate poisoning and obstetric emergencies (which account for nearly one-third of EMRI’s calls in India). The PGPEC curriculum also included chief complaint-based emergency medicine instruction, a feature not found in other EMS training programs.

The final curriculum incorporated classroom-based, hospital-based and prehospital-based components. The didactic curriculum was divided into 15 two-week modules. Each module was structured similarly to optimize resources and time, and allow for the simultaneous instruction of both students and instructor-trainees (Figure 4).

Figure 4: Two-week standardized modular curriculum demonstrating
concurrent training of paramedic students and instructor-trainees

During each educational module, US-based faculty provided on-site classroom-based lectures to both students and instructor-trainees using original PowerPoint presentations (Figure 5).

US-based faculty also conducted training-of-the-trainer sessions for the paramedic instructor-trainees, who learned to lecture and conduct hands-on procedural skills workshops under the direct supervision and mentorship of the US-based faculty (Figure 6).

Figure 5: Dr. Matthew Strehlow teaching at the
EMRI campus in Hyderabad

Figure 6: An ACE teaching intubation skills
to the PGPEC students

In addition to classroom-based lectures and hands-on skills workshops, the students participated in interactive case-based studies
(Figure 7), medical simulation and distance learning. The use of patient simulators allowed students to address real-life clinical scenarios and practice life-saving skills without the risk of harming a real patient (Figures 8, 9).

Through high-definition videoconferencing, leaders in emergency care from around the world were able to share their expertise directly with the PGPEC students in India without having to travel overseas.

The educational curriculum also included standardized international training courses such as Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and International Trauma Life Support (ITLS). When comparing ACLS test performance of 117 PGPEC students with 43 U.S. paramedic students, the average score was 86% (+/- 11%) for the Indian students, and 87% (+/- 6%) for the U.S. students. The PGPEC students performed at a level equivalent to their U.S. counterparts on ACLS written testing despite English being the third language learned for 75%.

Figure 7: Interactive case-based studies:
Treating the patient with chest pain

Figure 8: PGPEC students performing
the Heimlich maneuver

Figure 9: PGPEC students practicing ACLS
skills on a HD patient simulator

We also experimented with incorporating non-traditional subjects into our prehospital educational curriculum. All PGPEC students participated in an innovative two-week curriculum focusing on leadership, communication, team-building and personal confidence. Following completion of this unique educational program, PGPEC students reported significant improvement in their leadership and communication skills.

The PGPEC curriculum also included hospital-based rotations in emergency medicine, intensive care, coronary care, obstetrics and gynecology, pediatrics and burns. PGPEC students were supervised by ACEs and hospital-based physicians during these clinical rotations.

Prehospital field training was provided through direct observation, supervised practice via on-line medical direction, and case-based review (Figure 10). Students and paramedic instructor-trainees were continually assessed with written, oral and hands-on-skills testing.

Following completion of their didactic modules, hospital rotations and initial field training (18 months of training overall), the PGPEC students were administered a final written examination. Remarkably, all 120 students passed their final written examination on the first attempt.

For the final six months of the program, the students were assigned to field training locations throughout India. At the completion of this field training, the students returned to Hyderabad for final oral examinations (case-based) given by the ACEs and Stanford faculty. On July 16th, 2009, after two grueling years of training, the first batch of PGPEC students graduated, a proud moment for Stanford, EMRI and India. Since their graduation, the first batch of PGPEC students have gone on to work as paramedics, EMT instructors, researchers, and physician extenders, all across India.

Figure 10: Practicing use of the Kendrick field extrication device

Launching a paramedic educational program in India was not without obstacles and challenges. First, we had to recruit the right students and instructors to be successful. Remarkably, our students were willing to commit two-years of their lives to an unproven career path, and in doing so became part of the first generation of Indian paramedics. And, many of our ACEs left successful medical careers to join us and fill a needed void in EMS education in India.

Language also proved to be a significant barrier. Though all students had learned English, their true comfort and proficiency widely varied. They had trouble with ours accents and we with theirs. Many students struggled early on as our educational materials and instruction was in English. However, by modifying the curriculum to include medical English classes, small group sessions with the ACEs, and leadership and communication training, we observed a dramatic improvement in language proficiency over time. By their graduation, all of the students were facile with medical and conversational English.

As with all educational endeavors of this magnitude, attrition was a factor. A number of instructors and even some students left the PGPEC due to family commitments and illness, financial hardships, and alternative opportunities. Despite these hurdles, the overall retention rate and success of the PGPEC far exceeded our expectations. We proudly marveled as our students and ACEs developed into skilled clinicians, responsible role models and future leaders.

Over the course of our two-year engagement, Stanford sent twenty-five instructors (ten EM faculty members, three EM fellows, six EM residents, five students, four US-trained paramedics, and two nurses) to teach at the EMRI campus in Hyderabad. In July 2009, we turned over the complete responsibility for the paramedic-training program to the ACEs and EMRI staff, a defining moment in Indian EMS education. From 2007-2009, EMRI and Stanford established a novel, comprehensive paramedic training program that simultaneously trained its inaugural class of paramedic students and instructors, thereby ensuring future viability. It is our sincere hope that the EMRI-Stanford paramedic program will serve as a replicable paradigm for the development of sustainable educational courses elsewhere in India and in other developing nations.

References

Goodwin T, Delasobera BE, Camacho J, Koskovich M, D’Souza P, Gilbert GH, Strehlow MC, Mahadevan S.: Indian and U.S. Paramedic Students: Comparison of Exam Performance for AHA ACLS Training. Acad Emerg Med 16(4): Suppl_1:47, 2009.

Mahadevan S, Strehlow M, Chiao A, Ramana Rao GV, Shelke D, Rajhans P.: Development of a Self-Sustaining Paramedic Educational Program in India. EMCON, Guwahati, India, 2009.

Mahadevan S, Strehlow M, Jena B, Dubey A.: Epidemiology of Prehospital Emergencies in Andhra Pradesh, India, 2007. Ann Emerg Med 54 (3) Suppl 1: 80, 2009

Mantha A, Gupta A, Strehlow M, Mahadevan S.: Development of Focused Leadership Curriculum for Paramedic Students in India. EMCON, Guwahati, India, 2009

 

 

 

APOLLO EMT-INTERMEDIATE TRAINING PROGRAM
(2005 - 2007)

Stanford faculty and residents created and implemented a comprehensive EMT-Intermediate Program for paramedics at Apollo Hospital in Hyderabad and Chennai. These highly trained paramedics have had intensive field experience and some have gone on to become paramedic instructors, as well as ACLS/BLS instructors in India. They have played a crucial role in the development of EM/EMS in India.

"For much of India—and the developing world—emergency medical services that we take for granted in the United States are not available, and calls for help go unheeded. All of us with ties to India can recite an incident where a family member or friend met an untimely demise because of a lack of pre-hospital care." 
− S.V. Mahadevan MD, Interim Chair of Emergency Medicine