CONTENTS

EDITORIAL 4
Message from CEO
Editorial Board Venkat Changavalli

- Dr. G.V. Ramana Rao EDITORIAL ARTICLE 5

The role of Leadership in
- Dr. Anil Jampala Emergency Management Systems
an EMRI perspective
- Dr. Biranchi Jena Venkat Changavalli
- Dr. Mukul Saxena
RESEARCH ARTICLES 7
- Dr. Francis Raj Importance of Effective Emergency
Medical Transport in Addressing Maternal
- Dr. Saddichha Sahoo
Complications: Case Study, EMRI 108 EMS
Service in Andhra Pradesh
Dr. 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 21
Gopal Agrawal, Dr. Biranchi N. Jena

Medical Emergencies in Goa

A Preliminary Analysis 25
Dr. Saddichha Sahoo, Dr. Mukul K. Saxena

An Epidemiological Study of Emergencies

resulting from snakebites in Andhra Pradesh 30
Dr. Biranchi N. Jena, Dr. Nafeez S. Umar

REVIEW ARTICLES
Scorpion Sting 35
Dr. 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 52

Indian Emergency Journal (IEJ)
 MESSAGE FROM CEO

MESSAGE
FROM CEO

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

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
 EDITORIAL ARTICLE
The role of Leadership in EMS systems –
an EMRI perspective
- Venkat Changavalli
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
4
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
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.
Author: Venkat Changavalli
CEO - Emergency Management and Research Institute, Secunderabad, India
e-mail: Venkat_Changavalli@emri.in
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.
5
 LEAD
RESEARCH ARTICLE

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

Dr. G. Francis Raj

Abstract:
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

6
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
Author: Dr. G. Francis Raj,
Applied Research, Emergency Management and Research Institute, Hyderabad, India. e-mail: francisraj_g@emri.in
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
7
 • 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
13
countries.
• Postpartum hemorrhage has resulted in at least 25 percent of
the 5,00,000 maternal deaths globally. In some countries, this
14
number reaches up to 60 percent.
• 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
8
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.
Unlike other health emergencies which are typically unforeseen services more than any other districts with 7% and Hyderabad
and unplanned events that require immediate attention, pregnancy utilized lowest service (1%) for pregnancy cases (Fig-1).
and childbirth are natural process and careful planning and early Figure 1:
identification of complications can save the mothers’ lives.
Distribution of Pregnancy Cases Handled by
At a time when emergency medical services are significantly under 108 EMS Service from July 2007 to July 2008
developed in India, when compared to those in the developed world Vsknm Vznm
Srkm 4% 5% Wrgl
the Emergency Management and Research Institute (EMRI) was 6% 3% WG
established in Andhra Pradesh on the 2­nd of April 2005, as a unique RR 2% 5%
Adb
Prksm 6% 4%
Public-Private-Partnership (PPP) between the Government of Andhra
Nzbd Antp
Pradesh and the EMRI foundation to fill this gap in the state of 4% 7%
Andhra Pradesh. EMRI through its brand 108 Emergency Service Nlor
6% Chtr
provides complete pre-hospital emergency care from event occurrence 6%
to evacuation to an appropriate hospital.
Nlgd 3%
EG 4%
Since its inception, EMRI has significantly impacted in dispatching Mdk 2%
Gntr 5%
emergency personnel to the scene of emergency, conduct triage, provide Mbnr
7% Hyd 1%
Krnl Kdp
onsite treatment and transport patients to appropriate hospitals for 5% Krsn Khm Krmr 6%
4% 3% 2%
definitive treatment. Over the last three years since its establishment in
India, EMRI, through its flagship 108 Emergency Service has attended
The estimated number of live births in Andhra Pradesh in 2007 is
to over one million emergencies and saved lives.
approximately 15,00,000 lakhs as per the statistics of Department
Methodology: of Health and Family Welfare, Government of Andhra Pradesh.
In 2007 alone, with a fleet of 502 Ambulances in Andhra Pradesh Of these live births, 108 Emergency Services had handled 8.1% of
State and trained emergency medical technicians, EMRI has the overall pregnancies taking place in AP in 2007.
provided emergency medical transport and pre-hospital care to
Regional Distribution of 108 EMS Services: Andhra
over 1,30,000 women in labour. The process of addition of another
Pradesh consists of 23 districts including its State capital Hyderabad.
150 Ambulances to the existing fleet in Andhra Pradesh began in
There are broadly three regions in Andhra Pradesh; Telangana,
June 2008 and by end of August 2008, all 652 Ambulances were in
Andhra and Rayalaseema.
place. The present study is based on all the reported emergencies
associated with pregnancy from July 2007 to July 2008 in Andhra Telangana Region: Of the 23 districts, 10 districts, which are
Pradesh. Data collection was done using a pre-prepared Pre- located on the North-West side of Andhra Pradesh bordering
Hospital Care Record (PCR) by the emergency medical technician Maharashtra, Chattisgarh and Karnataka States form Telangana
in the Ambulance. After thorough verification of data only region. The Telangana region consists of Hyderabad, Adilabad,
1,21,454 eligible cases were selected for the study. Three types of Karimnagar, Warangal, Nizamabad, Medak, RangaReddy,
records were used for the studies which are collected by EMRI. Nalgonda, Mahabubnagar and Khammam districts. Based on the
They are emergency response records, which are maintained by the 2001 Census, these districts together consist of nearly 41% of the
emergency response officer, pre-hospital care records which are total population of Andhra Pradesh.
written by the emergency medical technician in the Ambulance and
48-hour follow-up records. Andhra Region: The Andhra region consists of 9 coastal
districts which are located towards the eastern and north eastern
Results: side of Andhra Pradesh bordering Orissa and Tamilnadu
Regarding the utilization of 108 Emergency Services the data States. Andhra region consists of Nellore, Prakasam, Guntur,
shows that utilization of 108 Emergency Services for pregnancy Krishna, West Godavari, East Godavari, Vishkapatnam,
related emergencies is not evenly spread throughout the State. As Vizianagaram and Srikakulam districts. Based on the 2001 Census,
per the data, pregnant women and their families in Ananthapur these districts together consist of nearly 41% of the total population
and Mahabubnagar districts have utilized the 108 Emergency of Andhra Pradesh.

9
 Rayalaseema region: The Rayalaseema region consists of Figure 2:
4 districts which are located towards the South-Western side
Age Distribution of Pregnancy Cases
of Andhra Pradesh bordering Karnataka State. Rayalaseema
25-29 30-34
region consists of Ananthapur, Chittoor, Kadapa and 5133 (4%) 35-39
30866 (25%) 1500 (1%)
Kurnool districts. Based on the 2001 Census, these districts 40-45
957 (1%)
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 15-19
10507 (9%)
were deployed in Telangana region, 38% were deployed in 20-24
Andhra region and 19% were deployed in Rayalaseema region. 72491(60%)

Data suggests that even though the percentage of Ambulance

Geographic Distribution of Pregnancy Cases
deployment in Telangana region is more based on population
The distribution of pregnancy cases across the State shows that
distribution of the State (Census 2001, Telangana region 41%,
108 EMS service is used mostly (93.2%) by women living across
Andhra 41% and Rayalaseema 18%), the utilization of 108
the rural areas and women living in tribal areas which is 2.5% of the
Emergency service remains less compared to other regions. On
overall cases handled by 108 EMS service. Few women in urban areas
the other hand in Andhra region even though the deployment (4.3%) have accessed 108 EMS service for transport of pregnancy-
of Ambulances is marginally less, the utilization of 108 EMS related emergencies. Since other sources of transport are available
Services is quite high (Table-1). and accessible to women in urban areas, it is possible they may be
utilizing them. (Table : 2 )
Table 1: Regional Distribution of 108 EMS Services
Table 2: Geographic Distribution of Pregnancy Cases
108 services
Population % Area Frequency Percent
Region assessed by
(Census 2001)
Pregnant women (%) Rural 113144 93.2
Telangana
41% 31% Tribal 3025 2.5
(10 Districts)
Urban 5260 4.3
Andhra
41% 45%
(9 Districts) Total 121454 100

Rayalaseema
18% 24%
(4 Districts) The results clearly indicate that 108 EMS service has been successful
in gaining the trust of the people by providing accessible and quality
Age distribution: EMS service free of cost. This also fulfills the NRHM goal of

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)
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

10
had SC and ST population together 27%. The EMRI data shows that suffering from abortionrelated complications and 9% of women
41% of women from SC and ST communities had accessed 108 EMS had medical conditions complicating pregnancy. The rest 4% of
services. This establishes the fact that 108 Emergency Services have women were suffering from breech presentation and 3% each were
been able to make inroads into the rural and tribal areas and has been suffering from bleeding or other causes of undergoing Caesarean,
successful in building the trust of women and their families in SC and 3% due to fetal loss and another 3% due to convulsions and
ST communities to use 108 Emergency Services during pregnancy eclampsia during pregnancy. (Fig-3)
related emergencies.
Figure 3:
Table 3: Social Status of Pregnant women with Urban,
Rural and Tribal Classification
Cause of Emergency Details
Area BC OC SC ST Total N Abortions
8% Abnormal Presentations
Rural 46.4 12.9 28.6 12.1 100
N

N Bleeding in Pregnancy
4%
Tribal 22.4 5.9 15.4 56.4 100 (Before or After Delivery)
N Eclampsia Convulsionsin Pregnancy
Urban 45.8 17.2 28.1 8.9 100 N Foetal loss
N Medical conditionscomplicating
Total 45.8 12.9 28.2 13.1 100 pregnancy
10%
N Post Caesarian in labor
3%
Precious Pregnancy
Rural, Urban and Tribal Classification of Pregnant
N
3%
60%
3% 9%
women based on Social Status:
Table-3 shows social status of Rural, Urban and Tribal classification Women’s Health Status during Transport in 108
of pregnant women utilized 108 services.Among rural population Ambulance:
46.4% of pregnant women from backward communities, 12.9% of Of the total 1,21,454 women who were shifted to hospital for
women from other communities, 28.6% of women from Scheduled pregnancy-related reasons, data was available for 55,645 cases
Castes and 12.1% of women from Scheduled Tribes. Where as for all variables. The study results show that 5 out of 10 women
in Tribal area majority of pregnant women (56.4%) belongs to who were shifted to hospital (51%) were stable and their health
Scheduled Tribes, followed by 22.4% of women form backward remained statuesque during transport and nearly other 5 out
communities followed by 15.4 % women from Scheduled Castes. of 10 women’s health condition improved during transport.
Only 5.9% of pregnant women belongs to other communities in The health condition of only a few pregnant women (218)
tribal areas of Andhra Pradesh.
worsened during transport and fewer women (17) died before
the arrival of Ambulance or during transport in the Ambulance.
Economic Background of Women:
(Table-4)e 5:
Of the total that have accessed 108 EMS Services, majority of the
women were housewives (59%). Nearly 6 out of 10 pregnant women
Table 4: Victim’s Health Status during Transport
were housewives, 4 out of 10 women were daily wage labourers
(38%). Few women were self employed (1%) or employees (1%) Health Status Cases Percentage

or were students (1%). The study findings further reiterate the Improved 34,042 49.15
confidence and trust that 108 EMS service has built especially Status quo 34,990 50.51
among pregnant women from poor economic backgrounds in rural
Worsened 218 0.31
areas.
Died 17 0.02

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
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

11
 from hospital and 32.3% of women were stable and out of danger, services, there were 73 maternal deaths, 57 women died at home,
but still in hospital. The health condition of the remaining 1% of 7 women died in hospital, 3 died on the road side, one died on the
women (559) was still critical and another 163 women were sent highway, 2 died in a public place and 3 others died in other locations
away by the hospital or by the emergency medical technician of the (Fig-5).
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 FigurePlace
5: of Maternal Death during pregnancy
up. (Table-5). Road Side, 3 Others, 3
High Way, 1
Table 5: Victim’s Health Status after 48 Hours of
Hospitalization Hospital, 7

Health Status Cases Percentage Public-

Place, 2
All right and discharged
36867 66.25
form hospital
Stable, out of danger
18000 32.35
but still in hospital
Condition is critical 559 1.00
First Aid 163 0.29
Died 56 0.1 Residence, 57

Incident Location Details: Age Details of Women who Died Maternal Death:
Figure-4 shows incident location of pregnancy cases shifted to Of the 73 pregnancies that culminated in maternal deaths, 8 women
health facility by 108 services. 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
Figure 4: 2 belonged to 35 to 39 years age group and 2 other women were 40
Incident Location of Pregnancy Cases and above age group. (Table: 6)
7-Others
5037 (4%) Table 6: Age of Pregnant Women at the Time of Death
6-Work Place
5-Road Side 228 (0%) 1-HighWay
719 (1%) Age Frequency  Percentage
7795 (6%)
2-Hospital
5288 (4%) 15 - 19 years 8 11.0
20 - 24 years 39 53.4
25 - 29 years 17 23.3
30 - 34 years 5 6.8
3-PublicPlace 35 - 39 years 2 2.7
1455 (1%)
40 and above 2 2.7
Total 73 100.0

4-Residence
Occupation Details of Victims of Maternal Deaths:
100913 (84%) Majority of the women were housewives (52.1%) and daily wage
Of the 1,21,454 women who were pregnant, majority of the pregnant workers were 34.2%. The others include employee 2% and self
women (84%) were shifted to health facility from their residence. The employed 2.7%. (Table-7)
other women who were shifted to hospital were picked up either from Table 7: Occupation of Pregnant Women who Died
road side (6%), highway (1%), other places (4%) and a few were also shifted
Type of Work Frequency Percentage
from their workplaces. But nearly 4% of the women have used 108 EMS
Daily wage work 25 34.2
Services for inter-facility transport or referral. (Fig -4)
Employee 2 2.7
Place of Occurrence of Maternal Death:
House Wife 38 52.1
The combination of emergency response centre data, Pre-hospital
Care Records filled by emergency medical technicians in the Self Employed 2 2.7

Ambulance and 48 hours follow-up conducted records show that Not Specified 6 8.2
of the total 1,21,454 pregnancy cases handled by EMRI 108 EMS Total 73 100.0

12
Social Status of Women who Died Maternal Death: another 3 women whose condition was considered stable and out of
Most of the women who died belonged to the lowest strata of danger also succumbed to death. (Table-9)
income and low social status in the society (Table-8). 27 women
from SC community and 14 women from ST community either Table 9: Status of victim at the time of 48-hour follow-up

died due to complicating pregnancy or while giving birth. The Health Status Frequency
number of women dying from SC and ST community is very high All right and discharged from the hospital 9
when compared with the percentage of SC and ST population to
Expired 56
the total population. The other women who died include 25 women
Died at home during the interval between call
from other backward communities and 7 women from other 5
made to 108 service and arrival of Ambulance
communities. (Table 8)
Stable, out of danger, but still in hospital 3
Table 8: Social Status of Pregnant Women who Died
Total 73
Caste Frequency Percent
BC 25 34.2
Comparison of time taken to reach hospital and
OC 7 9.6 health outcome:
SC 27 37.0 The results of the study show that of the total 1,21,454 cases
ST 14 19.2 handled by 108 service, only 73 maternal deaths were recorded.
Total 73 100.0 Of the 73 maternal deaths, 5 women have already died before the
Ambulance reached incident location as per emergency response
Victims status at the time of 48-hour follow-up: center records (Table-10). In effect the maternal deaths taken place
after case taken up by 108 Ambulance are only 67 deaths. Another
At the time of 48-hour follow-up 56 women were already expired and
32 deaths have taken place at home or in the hospital based on
as per the emergency response center records 5 women have already
the 48 hour follow-up. These deaths came into light when patient
died during the interval between the call made to 108 Ambulance
follow-up was conducted at 48 hours. In this case Ambulance may
service and arrival of Ambulance at the incident location. The nature
or may not be assigned. In another case 6 women died even when
of the death clearly shows that victim or their family members either
the Ambulance took less than 30 minutes to shift the victim to an
could not judge the risk or identify the complications or neglected the appropriate hospital. Thirteen women died when the Ambulance
signs and symptoms and called Ambulance at the last moment. But took 30 to 45 minutes to reach the health facility and 10 women
the study results show that there were 8 postnatal deaths of women died between 45 minutes to one hour. More women (12) died when
who were discharged from the hospital on the ground that they were the Ambulance took more than an hour to shift the patient to the
alright but they died after reaching home due to complications and health facility.

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

Died during transport

Died at home or in
or at home as per
Average Time Taken hospital as per 48 hour Total
Emergency response
follow-up records
records

Died at home during the interval between call made to

108 and arrival of Ambulance or after discharge from 5 27 32
hospital

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

13
 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
14
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.
References 18. Daulaire N, Leidl P, Mackin MA, Murphy C, Stark L. Promises
to Keep: The Toll of Unintended Pregnancies on Women’s
1. WHO/UNICEF/UNFPA press release, 12 October 2007,
Lives in the Developing World, Washington, D.C., Global
‘Maternal Mortality Declining in Middle-income Countries;
Health Council, 2002.
Women Still Die in Pregnancy and Childbirth in Low-income
Countries’. 19. WHO. Unsafe Abortions, Global and Regional Estimates of
the Incidence of Unsafe Abortion and Associated Mortality in
2. NFHS-3. National Family Health Survey, Ministry of Health,
2000. 4th Edition, Geneva, 2004.
Medical and Family Welfare, Government of India, 2005-06.
20. Cohen S. Towards Making Abortion ‘Rare’: The Shifting
3. Save the Children. State of the World’s Mothers 2006: Saving
Battleground over the Means to an End, Guttmacher Policy
the Lives of Mothers and Newborns, 2006.
Review, Vol. 9, Number 1, Winter 2006.
4. Dileep V, Mavalankar, Rosenfield A. Maternal Mortality in
21. WHO. Unsafe Abortions, Global and Regional Estimates of
Resource-Poor Settings: Policy Barriers to Care. American
the Incidence of Unsafe Abortion and Associated mortality in
Journal of Public Health. 2005 February; 95 (2): 200-203.
2000 4th Edition, Geneva, 2004.
5. White Ribbon Alliance for Safe Motherhood/India, Saving
22. Weil L, Javet JC, Rebold A; Donnay F. Maternal Mortality
Mothers’ Lives, What Works, 2002.
Update 2002: A Focus on Emergency Obstetric Care. New
6. Maine D, Akalin M, Ward V, Kamara A. The design and York: UNFPA; 2003 [Accessed July 7, 2008].
evaluation of maternal mortality programs. Columbia
23. Loudon I. Death in Childbirth: An International Study of
University, NY7 Center for Population and Family Health,
Maternal Care and Maternal Mortality, 1800–1950. Oxford,
School of Public Health; 1997.
England: Clarendon Press; 1992.
7. UNFPA. Reproductive Health for Communities in Crisis:
24. Middleberg MI. Promoting Reproductive Security in Developing
UNFPA Emergency Response, 2001.
Countries Published by Springer, 2003. Page – 31.
8. WHO, UNICEF, and UNFPA. Maternal Mortality in 2000:
25. Stein. Jo. Health system failures result in maternal deaths
Estimates developed by WHO, UNICEF and UNFPA, 2000.
[Online] [08.12.1999] URL:(http://www.health-e.org.za/news/
9. UNFPA. Reproductive Health in Refugee Situations: An Inter- article.php?uid=19991204)
agency Field Manual, Geneva, 1999.
26. District Family Health Survey (DFHS), a pilot study of three
10. UNFPA, Fast Facts on Maternal Mortality and Morbidity. districts of Andhra Pradesh to estimate IMR, Fertility and
[Accessed September 1, 2006] MMR, Conducted by: Institute of Health Systems, Sponsored

11. UNFPA, Fast Facts on Maternal Mortality fand Morbidity. by Commissioner of Family Welfare, Government of Andhra

(Accessed September 1, 2006) Pradesh, 2000.

12. WHO/UNFPA/UNICEF/World Bank. Reduction of 27. Unpublished study conducted by Academy for Nursing Studies

Maternal Mortality, Geneva, 1999. and Women’s Empowerment Research Studies, Hyderabad,
India, 2003.
13. UNFPA. Reproductive Health Fact Sheet, 2005.
28 Sample Registration System (SRS), 2003, Registrar General of
14. McConville B. Preventing Postpartum Hemorrhage, LIVES: India, New Delhi, India.
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.

15
 ORIGINAL RESEARCH
ARTICLE

Impact of EMRI Services on the

Public Healthcare System Delivery
Dr. Biranchi N. Jena

Abstract:
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
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

16
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
17
 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
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)

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

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 It has been noticed that EMRI provides more support to the rural
care systems. The case for India is more critical in this respect as the health system by handling more pregnancy-related emergency cases
existing health system fails in uplifting the institutional deliveries to 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
reduce the MMR.
by EMRI and from this period EMRI started its operation in rural
Andhra Pradesh.
Table 2: Total Number of Pregnancy cases handled by
EMRI Considering high association between MMR and the institutional delivery,
EMRI has enabled the public healthcare system to reduce the MMR by
Total Number of % share of total approximately 18% in Andhra Pradesh. If the same estimation has to be
Year Pregnancy cases Emergencies done for India, EMRI be would able to contribute around 23% to 38% in
handled by EMRI handled reduction of the MMR once its operation expands to the whole of India.

The rural primary health centers are woefully underutilized because

2006 2528 2%
they fail to provide their clients with the desired amount of attention
and medication and because they have inconvenient locations and
2007 65009 17%
long waiting times.5 EMRI has enabled the overall health system
2008 to increase the healthcare facility utilization in Andhra Pradesh
293095 20% by ensuring access to efficient and effective prehospital transport
(estimated)
Source: AP EMRI. with adequate care. In the process, healthcare facilities are receiving
the victims in less critical conditions because of the effective pre-
EMRI’s contribution in increasing institutional delivery and births hospital care and the victim reaches the care unit with all the vitals
assisted by trained personnel has been significant, as currently it measured by the trained medical technicians in the EMRI life
is providing service to 20% of the total live births taking place in saving ambulances. This process reduces the unnecessary delay at
the state of Andhra Pradesh. The total proportion of pregnancy the healthcare unit and the treatment gets optimized. Thus EMRI
cases reported to EMRI has increased to around 20% in 2008 as enables the healthcare system to increase the probability of survival
compared to only 2% in 2006. drastically in case of medical emergency which was completely

18
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
19
 ORIGINAL RESEARCH
ARTICLE

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

Gopal Agrawal
Dr. Biranchi N. Jena

Abstract:
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
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’.

20
Introduction
Emergency 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,
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
Authors:
Gopal Agrawal,
Research Consultant, Emergency Management and Research Institute, Secunderabad, India. e-mail: gopal_agrawal@emri.in
Dr. 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.
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
21
 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 Table
Life 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.
Mx: Age-specific death rates of population under study. It is the
n
basic input of life table.
22
Total mumber of deaths in age (x, x+n) in a year
nMx=
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.
2 * n * nMx
q =
n x
2 + n * nMx
• ndx: Number of persons survived age x but died before completing
age x+n. d = lx * nqx
n x
• nLx: Average number of person-years lived by a hypothetical
cohort of age (x, x+n).
n
L =
n x * (lx + lx + n)
2
• 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:
Total number of death in age (x, y + n) space in a year - No. of lives saved in age (x,x + n)
Adjusted nMx=
Mid - Year population age (x, x + n)
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 Discussions
Table 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.
 Table 1: Adjusted and Unadjusted Life Expectancy at birth for Andhra Pradesh, 2005-07

Year Total

SRS Adjusted** Increase (in years)

2005 64.03 64.05 0.03

2006 64.33 64.48 0.15
2007* 64.53 64.90 0.37

Male
Year SRS Adjusted** Increase

2005 62.55 62.56 0.01

2006 62.89 63.09 0.20
2007* 63.0 63.49 0.49

Female
Year SRS Adjusted** Increase

2005 65.21 65.24 0.04

2006 65.65 65.75 0.09
2007* 65.64 65.88 0.24

*Projected figures: Liner rate of projection has been adopted.

**Adjusted Life Expectancy at birth obtained after incorporating life saved data in life tables.

Conclusion
The 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.
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

23
 ORIGINAL RESEARCH
ARTICLE

Medical Emergencies in Goa -

A Preliminary Analysis
Dr. Saddichha Sahoo
Dr. Mukul Kumar Saxena

Abstract:
Background: Most emergencies in Goa arise due to road traffic accidents and Medical Technicians (EMTs) were placed in the casualty of the medical colleges
drownings, which have been compounded by the rise in number of recorded and recorded the data on the data sheet. The collected data was then analyzed
accidents in 2007 to above 4000. It is believed that an average of 11 people for stratification and mapping of emergencies.
meet with an accident on Goa’s roads every day and this is expected to rise by
10% by next year. Results: GMC Hospital attended to majority of emergencies (62%), which
were mainly of the nature of accidents or assaults (17%) and fever-related
Aim: Since emergency services were launched in Goa by EMRI in the first week of
(17%). Most emergencies were non-critical and were transported with the help
September 2008, we aimed to conduct a pre-launch cross-sectional survey of medical
of cars (17%), taxis (17%) and buses (17%). Maximum emergencies also
emergencies and various types of emergencies which may present to 108 services. We
presented from Salcette and Bardez, and occurred among young males in the age
also attempted to identify various modes of transport which are used to currently
group of 19-45 years.
transport emergencies currently to hospital care.

Method: On a prospective basis, all emergencies presenting to the three Conclusion: Potential emergency services need to target young males with higher
government hospitals in Goa, which handle 90% of all emergencies currently, concentrations required in Salcette in South Goa and Bardez in North Goa.
were studied on specially designed data sheets in order to collect data. Emergency Key Words: Emergencies; Goa; Mode of Transport; Outcome

24
Introduction: Aims and Objectives:
Goa, India’s smallest but richest per capita state, with a population This study attempted to
of 1.3 million people, became a part of India only in 1961, before
1. Identify various types of medical emergencies which may
which it was governed directly from Portugal. The state of Goa
present to 108 services.
consumes a large quantity of alcohol and has also accepted alcohol
2. Identify specific variables associated with these emergencies in
as a social beverage, the repercussions of which are obvious today.
order to put in place additional measures to reduce number of
One of the most serious of these has been the massive increase in
deaths.
the number of road traffic accidents and accidental drownings.
3. Identify and target specific causes for intervention.
A rapid explosion of road traffic accidents has been observed with
4. Identify various modes of transport which are used to transport
2,800 recorded accidents in 2001 doubling to above 4,000 in 20071.
emergencies currently to hospital care.
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
Method:
6% over the previous year2. It is believed that an average of 11
Using a stratified random sampling design, records of all medical
people meet with an accident on Goa’s roads every day and this
emergencies presenting to the three government hospitals, namely
is expected to rise by 10% by next year. The Police Department
Goa Medical College Hospital (GMC), Asilo Mapusa and Hospicio
has reported that till date in 2008, there have been approximately
Margoa, were prospectively studied on specially designed data
150 fatal accidents3. Most accidents involve mainly 2 wheelers in
sheets in order to collect data. These hospitals currently serve as
Goa and occur around 8 pm in the night. In addition, there have
primary referral centre for nearly 90% of all emergencies. Trained
been at least one or two drowning deaths per week accounting for
paramedic personnel or EMTs were utilized for the purpose of data
a large number of accidental deaths in Goa. The Director, Goa
collection after a detailed training on using the data sheet. Once
tourism department has reportedly informed the media that most
trained, these EMTs were then placed in the casualty ward of the
drownings are fatal due to lack of medical attention at the right
three government hospitals in three continuous 8-hour shifts. Data
time4. A large number of both forms of accidental deaths have
was collected over a 4 day period from 01st Sep to 04th Sep 08,
been linked to the wide epidemic of substance use, which in turn
with a 24 hour round-the-clock collection ensuring that no cases
increases both mortality and morbidity rates. Currently, transport
went missing. All data so collected by the end of study period
of emergencies is being done by public transport including auto-
was entered into a database and further analysed to detail type of
rickshaws and taxis.
emergency, location of emergency, transport of emergencies and
Now that emergency services have been newly launched in Goa by other variables associated with medical emergencies.
EMRI, it is vital that a pre-launch cross-sectional survey of medical
emergencies which may present to 108 services be carried out in Results:
order to understand the complexities involved so that these may be A total number of 360 emergencies were seen over a 60-hour period. A

targeted by the 108 emergency services. In addition, future studies majority of the emergencies were handled by GMC (62%) followed by

may be designed to study the impact that 108 services has had on Asilo Mapusa (23%) and Hospicio Margoa (15%). A higher incidence

mortality rates once baseline data is collected. of emergencies was also noted among males (64%) and in the 19-30

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

25
 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

Age distribution of emergencies in Goa

15%
21%
7% Below 10 years
11-18 years
12% 19-30 years
31-45 years
46-60 years
7% 38% Above 60 years

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)

Figure 2: Types of emergencies

Types of emergencies in Goa

Abdominal pain
Accidents and assaults
7% Cardiac-related
10%
1% 17%
Poisoning and overdose
9% Falls and fractures
5% Pregnancy-related
37% Fevers
17%
Animal bites
5%
Head injuries
Unconsciousness
8% 18% Others

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)

Figure 3: Status at hospital of emergencies

Status at hospital of emergency victims

1%
9%
Critical
Non-Critical
Expired

90%

26
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)

Figure 4: Mode of transport of emergencies

Transport of Emergency in Goa

11% 13%

Auto
12%
Car
17%
Bus
Wheeler
Taxi
17%
14% Ambulance
Others
16%

A stratification of emergencies by talukas resulted in the maximum personnel ensured that emergencies were handled with sensitivity
emergencies presenting from Salcette and Bardez, each accounting and accurate clinical data was collected.
for above 20% of all emergencies. Tiswadi accounted for about
15-20% of emergencies, while a lower incidence was seen in the The results observed that the majority of all emergencies were
remaining talukas. (Table1) 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
Table 1: Distribution of Emergencies
therefore that GMC Hospital attracts all kinds of emergencies and
Taluka Incidence of Emergency from all places in Goa including the border areas of Sawantwadi in
Maharashtra and Karwar in Karnataka. Emergencies were also noted
Pernem in the majority of males and in the age group of 19-45 years, making
Sanguem
this a vulnerable age group to be targeted for prevention policies.
Satari
Bicholim > 5% Further, since young males are also most vulnerable to vehicular
accidents and assaults, this also makes this type of emergency as the
Quepem
Mormugao 5-10% most common one followed by febrile emergencies. In addition,
Ponda cardiac-related emergencies were also frequently reported, making
Tiswadi 15-20% this a high priority area to target during service delivery.

Bardez
>20%
Salcette
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
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.

27
 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.
28
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.htm
3. 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.
 ORIGINAL RESEARCH
ARTICLE

An Epidemiological Study of Emergencies

Resulting from Snakebites in Andhra Pradesh
Dr. Biranchi N.Jena
Dr. Nafeez S.Umar

Abstract:
Background & Objectives: Snakebite is an important and growing cause of area, time of bite, season and response time etc., are studied with reference to
morbidity and mortality in different parts of the world, especially in south the survival of the victim.
Asian countries. It has been observed that most of the snakebite victims suc-
Results: More Snakebite cases are reported from rural area as proportion of
cumbe to death due to non-availability of quick and quality emergency medi-
victims in rural and urban area is found to be 12:1. Males were more victim-
cal support. This study was undertaken to find out the epidemiological profile
ized in the event of snakebite (57%) as compared to the females. The results
of the snake bite victims and to examine association of socio-demographic and
observed that 325 (37%) of the total snakebite victims are in the age group
other variables with the survival of the victims.
20-30 years. About 47 % of cases were observed in the period from June to

Material and Methods: 5155 snakebite emergency cases were reported to September which coincided with maximum rainfall in Andhra Pradesh and

Emergency Management & Research Institute (EMRI) from the state of quantum of rainfall is found to be highly correlated with snakebite cases re-

Andhra Pradesh in 2007. Based on the variables required for the study and ported to EMRI. The major symptoms observed at the time of attending the

their availability, 877 snakebite cases were selected from Pre-Hospital Care snakebite cases were difficulty in Mobility, Swelling and Bleeding.

Record (PCR) of EMRI for the current study. Variables like age, gender, Key words: Snakebite victims - epidemiological profile

29
 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.in
Dr. Nafeez S.Umar, Associate Partner, Research and Analytics, Emergency Management and Research Institute,
Secunderabad, India. email: shaiknafeez_umar@emri.in
30
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]
 Majority of the snakebites occurred at day time (72.5%) than the
Table 1: Descriptive statistics for Snakebite cases in
Andhra Pradesh night time (27.5%). As it is already noticed that more than 90%
of the cases are reported from rural area, responding to 48%
Parameter Frequency (%) cases took more than 30 minutes, while 35% cases the emergency
services provided in 10-30 minutes and 17% cases it was less than
GENDER 10 minutes. [Table-2].
376 (42.9)
Female
Male
501 (57.1) Table 2: Distribution of Snakebite cases by
different time period
AREA
810 (92.4) Time/Period Frequency(%)
Rural
67 (7.6) Dry Season (Oct-May) * 466 (53.1)
Urban
Rainy Season(June-Sept) 411 (46.9)

INCIDENT LOCATION MONSOON

443 (50.5) 6 (0.7)
Outside Residence Winter (Jan-Feb)
434 (49.5) 68 (7.8)
Residence Pre Monsoon (Mar-May)
411 (46.9)
Middle Monsoon (June-Sept)
OCCUPATION 489 (55.8) 392 (44.7)
Post Monsoon (Oct-Dec)
Daily Wage Workers
147 (16.8)
Housewife DAY-NIGHT
122 (13.9) 636 (72.5)
Others Day
Student 63 (7.2) 241 (27.5)
Night
AGE 29 (3.3)
TIME OF BITE
0-10 114 (13) 331 (37.7)
10-20 Day (6-12)
284 (32.4) 241 (27.5)
20-30 Evening (12-18)
217 (24.7) 239 (27.3)
30-40 Morning (18-24)
66 (7.5)
40-50 119 (13.6) Night (24-6)
50 & above 114 (12)

SURVIVAL STATUS RESPONSE TIME (IN MIN.)

25 (2.9) 144 (16.4)
Fatal 0-10
852 (97.1) 307 (35)
Non fatal 10-30
426 (48.6)
30 & Above

Most of the snakebite cases were reported during the middle

monsoon (June-Sept) (46.9%) [fig.-1]. MONTH
January 2 (0.2)
Figure 1: Area-wise and monthwise variation in Snakebite
February 4 (0.5)
cases reported to EMRI
March 19 (2.2)
250 April 37 (4.2)
Rainy Season

200
Rural
May 12 (1.4)
Snakebites

150 Urban
June 16 (1.8)
100 Total
July 83 (9.5)
August 119 (13.6)
50
September 193 (22)
0
October 232 (26.5)
April

June

September
January
February

May
March

October

December
August

November
July

November 114 (13)

Months
December 46 (5.2)

31
 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]
Table 3: Association of snakebite cases with rainfall
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)
*Source: India Metrological Department, Mausam Bhavan, Lodhi Road, New Delhi
The most affected anatomical area was reported as lower limbs
(56.3%) followed by upper limbs (20.9%). Information not
of providing the pre-hospital care. One hundred fifty one victims
(17%) had no symptoms recorded. [Table 6]
Table 5: Association between Socio-Demographic vari-
ables with survival status
Parameter χ2 value for association-
ship with survival status
Response time 2.275 ns
Day/Night 0.162 ns
Time of reporting 4.448 ns
Month 34.52 ns
Monsoon 24.734 **
Victim’s age 6.964 ns
Gender 0.013ns
Incident Location 4.696 ns
Occupation 2.292 ns
Note: **: Significant at 0.01 levels Ns: Not significant at 0.05 levels

available accounted for (18.6%) of the total cases. [Table-4] In case of snakebite, major pre-hospital care intervention includes
IV fluids, Oxygen and wound care. Chi–square test is performed to
Table 4: Distribution of Anatomical area of injury for the check the association between different presenting symptoms on
reported Snakebite cases to EMRI the victims and the pre-hospital care. It is observed that difficulty
in mobility was major symptoms at the time of pre-hospital care
Anatomical area of injury @ Snakebite (%)
given and oxygen as a pre-hospital care is significantly associated
with difficulty in mobility (p<0.01). IV fluid intervention is also
Upper Limbs 183 (25.63)
Lower Limbs 494 (69.18) Table 6: Number of Symptoms seen at the time of snakebite
Multiple regions 37 (5.00) Number of Symptoms at the time of Snakebite Frequency (%)
Information not available 163 (18.6)
Nothing recorded 151 (17.0)
Total 877 (100) Single Symptom 247 (28.0)
Two Symptoms 259 (30.0)

Three or more Symptoms 226 (26.0)

The present study was analyzing the significant association between
the different types of socio and demographic variables with their significantly associated with symptoms like unconscious, swelling
survival status. It was observed that survival status is significantly and vomiting (p<0.05). [Table-7]
associated with monsoon (p<0.01). As it was observed that most of Table 7: Association tables for Presenting Symptoms and
the snakebite cases were reported during the monsoon, the survival Pre care hospital
rate was 96% during monsoon, where as the rate is improved to Presenting
Pre-care Hospital
Symptoms
98.5% in post monsoon. It was also observed that the survival rate
IV Fluids Oxygen Wound care
was not significantly associated with time of reporting (day/night).
Unconscious 14 (8.731 *) 20 (6.01 *) 4 (0.700 ns)
The survival rate was higher (99%) for those cases reported in day
Swelling 70 (7.495 *) 116 (1.482 ns) 52 (4.643 *)
time than those cases reported at night time (93%). A minor variation
Vomiting 30 (3.948 *) 52 (4.20 *) 19 (0.348 ns)
was noted in the response time while handling the cases in daytime
Bleeding 34 (0.365 ns) 59 (0.650 ns) 46 (33.997 **)
and night. The response time in 51% of the total cases handled
Difficulty in Mobility 103 (1.118 ns) 210 (11.459 **) 71 (0.042 ns)
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 Shock 11 (0.253 ns) 19 (0.016 ns) 9 (0.569 ns)

significantly associated with the survival rate. [Table-5] 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)
Major symptoms recorded in PCR were difficulty in mobility Difficulty in Speech 36 (3.81 ns) 61 (1.980 ns) 20 (0.086 ns
with Swelling bleeding, difficulty in speech and vomiting. Out of
Note: Parentheses indicating Chi-Square values
877 victims, there were 259 (30%) victims having two symptoms **: Significant at 0.01 levels
present and 247 (28%) having only one symptom visible at the time *: Significant at 0.05 levels .Ns: Not significant at 0.05 levels

32
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.
33
 REVIEW ARTICLE
Scorpion Sting
Dr. H.S.Bawaskar
Dr. P.H.Bawaskar
Abstract:
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,
34
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.
Introduction
Scorpion 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 2/3 rd
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
7
manifestations . Venezuela reported children with high fatality . 13 8 oldest known terrestrial arthropods. Fossil scorpions found in
out of 78 cases died due to scorpion sting as stated in a report from
9
Mahad region . In rural hospitals from western Maharashtra, India
3,546 scorpion sting cases are reported in one year, of these 542 had
10
systemic involvement . 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
13
in 2005 . 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
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
31
mother to death (cannibalism) . Scorpions belong to venomous
35
 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
Figure 1
these are potential lethal to humans (Fig.2)32.
Figure 2
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
36
(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)
Figure 3
Venom
Tail 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
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
1, 3, 6, 17, 24, 40
similar 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
41
severe, when extremities became warm is a sign of recovery
On the clinical presentations or course in hospitalized patients are
divided into 1 - Severe local pain only 2 - systemic involvement.
Local pain
Severe 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 periphery . According 32
to clinical manifestations, they are divided into three grades of
II, III and IV. All cases had initial sign and symptoms suggestive
of autonomic storm . Grade II – hypertension or transient
3 disoriented with or without pulmonary edema suggestive of warm
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.
Hypertension
45% 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,
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,
37
 42% cases usually reported 8-26 (mean 150 hours of sting with Figure 5: Batwing after 4 hours
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.
Investigation
Leukocytosis 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
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:

38
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
. Scorpion sting is un-noticed sudden onset of a accident. Majority
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
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-physiology
Delayed 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
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
39
 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
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,

In experimental pharmacokinetic studies with radioactively labeled
left ventricular impendence a without rising heart rate. It reverses
scorpion venom given intravenously, it was observed that the half
the metabolic syndrome evoked due to excessive catecholamine80.
life of venom distribution and its excretion were 5.6 minutes and 6.4
Prazosin is a pharmacological and physiological antidote to venom
hours respectively91. Other similar studies using antivenin showed
action39, 99
. Three victims developed severe pulmonary edema
that the half life of distribution was 1-9 hours with the result of
irrespective of 5 ampoules of scorpion antivenin recovered with oral
these studies it is concluded that antivenin therapy was inefficient
prazosin a recent report from Saudi Arabia 45 similar observations
because no interaction could occur between scorpion toxin and
are reported from Tunisia 100. Morbidity and mortality depend upon
antitoxin, justified the use of prazosin and dobutamine92. IgG
time lapsed between sting and administration of prazosin, since the
distribution half life was tenfold longer than that of venom which
advent of prazosin the fatality is reduced to 1% 28.
was short (32 min). In comparison to immunoglobulins, venom
distributes fast and achieves greater concentration with a shorter
Massive life threatening pulmonary edema due severe hypertension
time needed to achieve its maximum concentration72. Severe
or delayed reporting of victim to health center or attended doctor
clinical manifestations due to scorpion sting are alleviated in victim
failed to administer the prazosin or inadequate dose of prazosin
if the antivenin is given within one hour after sting93. However
which advocated three hourly intervals or giving excessivee
delayed administration of scorpion antivenin did not prevent the
diuretics, IV fluids, atropine, steroids and antihistamines. These
pulmonary edema 94. All the ten cases had severe cardiovascular
cases to be treated with intravenous nitroglycerine or sodium
manifestations, irrespective of administration of scorpion
nitroprusside drip. 7-10% pediatrics cases developed marked
antivenin of these 5 recovered with prazosin and four required
tachycardia, hypotension with warm extremities called “warm
inotropic support and one died, according to a report from western
shock” necessitates dobutamine drip27, 48.
Maharashtra India95. The persistence of signs and symptoms of
envenoming after neutralization of circulating venom could be Many toxins from scorpion venoms activate sodium channels,
explained by the inability of antivenin to neutralize scorpion toxins thereby enhancing neurotransmitter release. On this basis Fantail
96
bound to their receptors on the sodium channel . A number etal in experimental study showed beneficial effects of intravenous
of specific scorpion antivenins are available but their efficacy is lignocaine, a sodium channel blocker101.
uncertain. Ancillary treatment with vasodilators is crucial in severely
envenomed patients79. Administration of scorpion antivenin after Seven young patients admitted with history of scorpion sting
one hour of sting did not prevent the development of pulmonary presented with pulmonary edema was successfully managed with
edema8, 27 and cerebral edema (Romero NO, Hernandezt JM 2005), positive pressure ventilation with PEEP, cardiac support with
cardiac arrest (Dittrich K, Ahmed R, Ahmed QAA 2002). inotropic and fluid balance according to a report from Nepal 102.

40
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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44
in scorpion sting (2007). http://www.swamisamarth.com
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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
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.

45
 REVIEW ARTICLE

Challenges in Emergency
Management Research
Dr M K Saxena

Abstract:

“EMS research is a work in progress. There are no easy answers for some, the window has yet to be built. Our challenge is to
and no easy methodologies – but nothing worthwhile is ever intervene on those issues where the window is still open and
easy. For some issues, the window of opportunity for necessary carefully craft the windows of the future.”

research has closed. On others, the window is closing fast. And Elizabeth A Criss1

46
Emergency management is a response to a situation which may uniform evaluations of emergencies and comparing outcomes.
rightly be termed as ‘predictable surprise’ which by the very virtue Unfortunately, most published research in EMS is component
of its nature is unpredictable to the victim, life threatening and based, focusing on a single intervention or health problem and
largely due to circumstances beyond his control, but contradictory rarely addressing the inherent complexities of EMS systems1
though it may sound, can be predicted by research methodologies.
The design of experimental research under pre-hospital conditions
In a large majority of cases, the victim may not be in a position to
is by itself a major challenge. Biases in emergency service
seek medical treatment. In a number of cases, especially road traffic
medicine research relates to variability of EMS personnel and their
accidents even the bystanders may be reluctant to take the victim
qualification and hence it may not be possible to prove efficacy
to a medical facility due to medico legal issues, leading to lives lost
and efficiency in emergency management practice.8 Hopefully this
that can potentially be saved. Evolution of emergency management
situation is likely to change with institutes training them on standard
services is still in its nascent stage. USA made a beginning in 1968
curriculum .
through 911 services. California passed its EMSS act as late as
1973.2 China, the most populous country introduced EMS in 1980,
Unlike other spheres of clinical research, research in EMS, does not
with a predominant urban focus. The ‘Rescue centers’ provide both
have to follow the animal experiments, and has to make a beginning
ambulance and inpatient care.3 Madagascar with a population of 15
with retrospective data that is available. The challenges a researcher
million has again an EMS with urban bias.4 Japan has an EMS run
faces are in data interpretation / validation. As most EM services
by fire defence headquarters and is basically a single tiered system.5
are oriented towards pre-hospital care, retrospective data is often
India, the largest democracy, and the second most populous country
silent on certain specific aspects such as the diagnosis. Should
in the world had its first comprehensive emergency medical services
one consider the diagnosis based on the interpretations of clinical
rolling out in 2005, with advent of Emergency Management
findings by a trained paramedic, or the researcher’s own inclusion
& Research Institute (EMRI). Israel, a small nation of 7 million
and exclusion criteria, or hospital diagnosis obtained subsequently?
population has an EMS service that attends to approx. 1000 calls /
This in turn brings up the challenge of the issue of confidentiality
day and in addition has mobile teams to be dispatched to scenes of
and right to privacy of individual. The issue of linking with patient
international disasters.6
outcomes shall depend on certain established information systems
Indonesia, the fourth populous country in world has an emergency within the EM services as well as with the hospitals.
medical services functioning, with only 26 ambulances covering
The emergency services do not have the existing research backup so
Jakarta, having an area of 661 sq. k.m. and a population of 10-
essential to any research field. There is hardly any academic research
12 million population. The service receives 1500-1800 calls per
institution with long term commitment to EMS research. Most of
month.7 When this is compared with 31,526 calls received by EMRI
the institutions which do carry out research on EM subjects pertain
services in one city only i.e Hyderabad for the month of August 08,
to the Emergency room admissions and ICU interventions.This is
it shows the extreme of disparity in the number of calls attended.
a challenge that EMRI seeks to address. Research in EMS through
Such a situation when translated into a database is an indicator
prospective studies is burdened by restrictive interpretations
of challenge posed to EMS research. The challenge increases in
of informed consent.The ethical issues get more challenging in
magnitude when one considers regional imbalances in terms of
scenarios that are bound to unfold when EM services are likely
illiteracy and poverty causing deficiencies in information given by
to increase their activities covering larger populations and areas
relatives of victims and competence of paramedics contributing to
where the increased load on emergency services shall lead to triage
database inconsistencies.
protocols. Research on pre-hospital interventions also needs to be
It is also true, that if decisions in EMS have to be evidence-backed sensitive to such challenge. The most important challenge stems
and not based on mere assumptions and hypotheses, it is a must, from the application of basic ethical principles to research in
that research must be incorporated into evaluation of protocols, emergency medicine setting involved in resuscitation in vulnerable
and procedures. The present challenges relate to systems design, population.9 A recent Academic Emergency Medicine Consensus

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

47
 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
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

National EMS Research agenda has identified barriers to research 8. Emergency Medical Services Systems Research: Problems of
as Primary and secondary. The primary barriers include paucity of past, challenges of the future. Spaite DW, Criss EA, Valenzuela
trained researchers with interest in EMS Research and paucity of TD, Guisto J. Ann Emerg Med.1995, Aug ;26(2): 146-52
funding. Secondary barriers include recognizing the need for EMS
9. Research and ethics in emergency medicine. Findings of
Research.11 In the Indian setting, EMRI stands out as an institution
a workshop. Dick W, Ahnefield FW, Encke A, SchusterHP ;
to create centre of excellence in EMS Research, and address these
anaesthetist 1996 May;45(5):413-9
challenges.
10. Resuscitation Research involving vulnerable populations:
The researchers around the world have tried to come around to
Are additional protections needed for emergency exception
some kind of consensus on certain issues and have identified them
from the informed consent. Baren JM,Fish SS. Acad Emerg
as the type of study (System study versus specific intervention),
Med.2005 Nov ;12(110:1071-7,
population under study, Physiological and anatomical scoring
methods, prospective definitions of interventions and meaningful 11. NATIONAL EMS RESEARCH AGENDA, Published:
outcome variables, relative outcome compared to known standards December 31, 2001; Available at http://www.nhtsa.dot.gov/
and prospective determination of statistical requirements.12 people /injury /ems/ems-agenda/EMS Research Agenda pdf
(online ref accessed on 26 Oct 2008)
However, notwithstanding the magnitude of challenges, research
in EMS has to break new grounds, come up with solutions that are 12 Challenges in Prehospital trauma services. Current issues
likely to help the EM Services achieve their objectives in a scientific and suggested evaluation tools. Pepe PE, Majo RF, Prehosp
and cost-effective way and share their experiences and insight with Disaster Med .1993 Jan-Mar;8 (1 suppl): 25-34
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

48
 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, Dr.M Anji Reddy, JNTU
Germany
Poster Presentation in progress Winners of Student Poster Competition
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.
Prof. I V Muralikrishna, JNTU
Demonstration on Robotic technology
49
 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.
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

Amit Prasad, SatNav Technologies Mr. P.S. Roy receiving Lifetime Brig. Madhusoodhanan (left), Col Masur
Achievement Award (center) Col V. N. Jha

Lt. Gen Sharma (center) with Brig. Session in progress Lt. Gen. Y.N. Sharma
Madhusudhanan (left) and Dr Ramana Rao

Dr Suresh David, CMC, Vellore Dr. Col. Kumud Rai, Max Heart & xxxxxx
Vascular Institute, New Delhi

50
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 Institute
Devar Yamzal, Medchal Road, Secunderabad - 500 014.
Ph: 91-40-23462222 / 2200, Fax: 91-40-23462178
email: 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
51
 Emergency Management and Research Institute
Devar Yamzal, Medchal Road, Secunderabad - 500 014, Andhra Pradesh, India.
Ph: +91-40-23462600, 23462602, 23462222 Fax: +91-40-23462178

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