From stretcher to where?

We are all Mumbaikars now. Television sledge-hammered the horrors home — the glass shards, the blood, the gore. Wherever we were, we felt the pain of Mumbai as terror called on the city again.

But expressing solidarity is not enough anymore. As terror strikes on civilian targets become the “new normal”, it is time to draw up a laundry list of things which we, ordinary citizens of this country, want.
“Security preparedness” is the talking point of the day. Yes, we need much better ground-level intelligence, a more-skilled, better-trained and better-equipped police force, and, above all, better coordination between the various agencies overseeing the counter-terrorism response. But that is not all.
An emergency response today cannot be crafted in silos. Being prepared equally includes medical preparedness as large-scale attacks on urban, civilian populations have become all too frequent over the past decade. These incidents often result in what experts call “Hospital Multiple Casualty Incidents” (HMCI) which are very challenging to hospital teams.
Faced with a catastrophe, our doctors and nurses are doing their best and saving many lives. But it should not be left to individual capability and commitment. The critical question: How geared is the “system” on the whole to deal with mass casualties? Last Wednesday’s blasts in Mumbai offered a stark example of the gaping hole between what ought to be and what is on this score: we saw many injured victims being bundled into trucks and taken to hospitals. The ambulances came later.
Subsequent reports have also revealed that Mumbai, though repeatedly hit by terror attacks, does not have a comprehensive emergency medical service (EMS). After the July 11, 2006, Mumbai train bombings, an attempt was made to set up an EMS Executive Committee to bring in a 9/11-style emergency system to Mumbai. The plan, like so many other plans, is yet to take off. We have also learnt that JJ Hospital, Mumbai’s biggest government hospital, lacks a trauma management centre though everyone knows that the “golden hour” after any major accident is critical to saving the lives and limbs of victims. Trauma management centres are not luxuries. They are absolute necessities in an emergency situation when victims may require a range of skills and specialist services. Once again, excellent ideas have been floating around and expert committees have recommended addressing this lacuna. But nothing has come of it.
This is not Mumbai’s predicament alone. Most of India’s cities are ill-equipped to deal with emergencies though there is no dearth of guidelines and recommendations. It is a bit rich to expect 100 per cent medical preparedness during an emergency if we tolerate glaring gaps in the functioning of burn wards, blood banks, ambulances, as well as acute shortages of doctors, surgeons, nurses etc all other times.
Medical preparedness in times of terror is being discussed worldwide. It has its own specific needs, which are being recognised by experts.
“Explosions can produce instantaneous havoc, resulting in numerous casualties with complex, technically challenging injuries not commonly seen after natural disasters. Because many patients self-evacuate after a terrorist attack and pre-hospital care may be difficult to coordinate, hospitals near the scene can expect to receive a large influx, or surge, of victims after a terrorist strike. This rapid surge of victims typically occurs within minutes, exemplified by the Madrid bombings where the closest hospital received 272 patients in 2.5 hours. Such a surge differs dramatically from the gradual influx of patients after infectious disease outbreaks or environmental emergencies such as heat waves. In addition, injuries to workers involved in rescue and recovery can lead to a secondary wave of patients. Healthcare and public health specialists, therefore, should anticipate profound challenges in adequately caring for the surge of victims following a terrorist bombing,” notes the United States Centres for Disease Control and Prevention in its 2010 report, In a Moment’s Notice: Surge Capacity for Terrorist Bombings.
The report, which put together recommendations by experts from multiple disciplines, has templates on 10 key areas: Emergency Medical Services System Response, Emergency Department Response, Surgical Department Response, Intensive Care Unit Response, Radiology Response, Blood Bank Response, Hospital Response, Administration Response, Drugs and Pharmaceutical Supplies and Nursing Care.
It is not that no one in India has thought along these lines. We have National Guidelines on Medical Preparedness & Mass Casualty Management and some state governments are in implementation mode. The website of the National Disaster Management Authority talks about medical management in the critical “golden hour”, the need for ambulances fitted with critical care equipment, followed by prompt treatment in hospitals and prevention of epidemics, management of chronic health effects and provisioning psycho­social care.
There is a long list of things which are being done, we are told: Licensed blood banks have been networked to cater to surge requirements during disasters; burn centres are being expanded to 30 beds each in all medical colleges, tertiary care hospitals, and districts with more than 10 Major Accident Hazard units with burn risks; trauma centres of varying capacities are being set up. And so on. But the gaps are huge. Late last year, the National Programme for Prevention of Burns set up by the Central government estimated that India has an annual burn incidence of 6-7 million, based on data from major hospitals when extrapolated to whole of the country — the second largest group of injuries after road accidents. Nearly 10 per cent of these are life-threatening and require hospitalisation. Approximately 50 per cent of those hospitalised succumb to their injuries. The burn scenario is grave not only due to the high incidence but also because of the absence of organised burn care at primary and secondary healthcare level. In Delhi, for example, there are less than 200 beds for burn management to cater to the need of a population of over 14 million. So there is a shortage that needs to be addressed.
There is talk about “disaster-resilient communication connectivity” to facilitate medical response. The taste of the pudding, however, is in the eating. The chief minister of Maharashtra, one of India’s richest states, said that for 15 minutes after last Wednesday’s blasts in Mumbai he could not get through to anyone on the mobile. Obviously, there is a lot more that needs to happen. Many hospitals have an emergency medicine department but not enough manpower.
The concept of emergency medicine as a speciality is catching up across the country. More than 40 medical colleges are in various stages of starting a course in emergency medicine.
All this is good news but, as we know from experience, a lot that exists on paper does not exist on the ground and a lot that exists on the ground does not function. One could resign oneself to the status quo and say “We are like that only.” But we live in times when we don’t have that luxury. We could be paying for the indifference with our lives.

The author writes on development issues in India and emerging economies and can be reached at patralekha.chatterjee@gmail.com