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Volume IX, Issue I

April 2018
Content

DIRECTOR MESSAGE
Chief Patron Message from Chief Patron & Director, GVK EMRI 01
Mr. K. Krishnam Raju Mr. K Krishnam Raju

Chief Editor EDITORIAL ARTICLE


Dr G V Ramana Rao Medical Equipment in EMS 04
Dr G.V. Ramana Rao

Associate Editor
Dr Sanket Pa l
ORIGINAL RESEARCH ARTICLES
The Essen al Prehospital Care Refresher Course 11
Peter Acker, Danielle Mianzo, Elizabeth Pirro a,
Editorial Assistants Ma hew C. Strehlow, Swaminatha V. Mahadevan
Ms. Aruna Gimkala
Ms. Rani Janumpally Effec veness of CBR Training on ASHA Workers 17
Ankita Brahmarout, Purva Rajendra,
Editorial Board Rajini Danthala, GV. Ramana Rao
Dr Manu Tandon
Do all Poster abstract presenta ons
Dr MNV Prasad
get due recogni on and publica ons
Dr Narmada Devi Hadigal compared to oral presenta ons? 33
Dr Raghav Du Kumara V. Nibhanipudi
Dr Raja Narsing Rao
Dr Rama Padma CASE STUDY
Dr Shailendra Singh Paraphimosis 39
Dr Srinivasarao J Kumara V. Nibhanipudi
Dr Tiameren Jamir
Dr V.S.V. Prasad REVIEW ARTICLE
Dr Vivek Singh Good Samaritan Law 43
Dr G.V. Ramana Rao

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 1


Indian Emergency Journal / Vol-IX / Issue-I / April 2018 2
DIRECTOR'S MESSAGE
EMS Research Today and Tomorrow

Na onal Ambulance Services (NAS)


facility, under Na onal Health Mission, in
March 2018, is available in 31
states/Union Territories (UT) in India out
of the total 36 States/UTs. '108' services
are predominantly catering to Common Review Mission Reports are
emergencies. '102' services essen ally documen ng the role of ambulance
consist of basic pa ent transport aimed services from me to me. At the central
to cater the needs of pregnant women government level, Na onal Ambulance
and children, though, other categories Code, Technical specifica ons of Medical
are also taking benefit and are not equipment for Emergency Response
excluded. 8061 ambulances are being Vehicles are documented. Health Sector
supported under 108; 8252 ambulances Skills Council (HSSC) has spelt out the
are opera ng as 102; 7603 empanelled curriculum and training standards of
vehicles are also being used in some basic and advanced EMTs. World Health
States to provide transport to pregnant Organiza on ( W H O ) has ini ated
women and children. Most of the States emergency care systems (ECS) and
are preferring to con nue these services capacity building requirement
through compe ve bidding process. standardiza on for lower and middle
The request for proposal (RFP) document income countries. The Government of
of emergency response services (ERS) is India has also ini ated a empts to
explicitly ar cula ng scope of services, streamline paramedical educa on
technology, manpower ra os, type of through an expert group. State level
ambulances, medical equipment, unit paramedical boards are registering 2-
cost and transparent selec on process. year trained Advanced EMTs. EMS
Even penal es to the service provider, in operators are leveraging technology,
case of devia on and default, are also op mizing services. Thus emergency
made clear. Na onal Health Mission is response services are stabilized on most
closely monitoring and reviewing the of the fronts. With these important
performance of 108 and 102 services.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 3


building blocks in place, EMS research determined ques onnaire. OLMR also
need to be focussed in future. r e v e a l s a c o m p a ra v e s t a t u s o f
performance of different states under
GVK EMRI always believed 'Research' is GVK EMRI. Thereby, specific areas of
an integral part of private partner's immediate improvements in services and
contribu on. Accordingly, Opera ons training can be selected. These are close
and Analy cs research department to the PIP (performance improvement
supported by technology is able to plans) in other EMS systems. GVK EMRI
generate ambulance based data on has realized importance of working with
mul ple parameters. Resource u liza on the other EMS systems in Asian region in
is being monitored. Opera ons units are research. Crea on of Registry for Out-of-
perusing the near real me data in Hospital-Cardiac Arrests (OHCA) and
monitoring and improving services Trauma Registry are firm steps, to leap
through “Opera on Excellence Desks- frog in research front in the coming years.
OED)” in Emergency Response Centre at There is a scope to propose projects for
every state level. Hence, there is a need funding from na onal and interna onal
to strengthen these research ini a ves agencies. There is an immense need to
not only to op mize resources to make carry out joint research and create pilots
services cost effec ve, but should also and Proof Of Concept (POC) on several
expand to clinical care audits to measure p re h o s p i t a l s e r v i c e d i m e n s i o n s .
and improve prehospital care in coming Simula on based educa on in life
years. support skills can be a special area for
considera on in research as India and
GVK EMRI and Stanford Emergency other developing countries require huge
Medicine Interna onal (SEMI)-USA capacity building focus in the next one
collabora on in research, has now decade. GVK EMRI, so far, was involved
sta r te d s h o w i n g re s u l t s t h ro u g h in Resuscita on guidelines, ST eleva on
publica ons in high cita on index Myocardial Infarc on (ST E M I) and
journals. On-Line-Medical-Research Trauma c Brain Injury (TBI), prehospital
(OLMR), a unique prospec ve research trauma care guidelines development in
technique, enables data collec on the Indian context. GVK EMRI has
through out-bound calls, from ten GVK created processes to welcome
EMRI opera ng states, on a par cular internships from premier ins tu ons in
type of emergency, through a pre- India and other countries, to encourage

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 4


inter-ins tu onal EMS based research to
create meaningful inferences towards
improving pa ent care.

GVK EMRI is now reaching about 800


million people in India and Srilanka
through a fleet of 11000 ambulances and
46,000 associates and all in public-private
p a rt n ers h ip ( P P P ) m o d e. H en c e,
governments at all levels should be
sensi zed about the need for appropriate
research to favour policy implica ons in
the medium and long terms. I am
delighted to men on that GVKEMRI has
published more than 108 number of
scien fic papers. Indian Emergency
Journal (IEJ) is a pla orm to disseminate
good quality research in E M S of
developing world.

With Warm Regards,


Mr K. Krishnam Raju
Director- GVK EMRI

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 5


6
EDITORIAL ARTICLE
Medical Equipment in EMS
Dr G V Ramana Rao
With the advent of recent advances in
educa on, care, research, technology
and changes in policies in prehospital
care, EMS providers are able to diagnose,
stabilize and manage acute injury and
illness. Equipment is necessary for
systems are categorized into 'basic',
carrying out procedures. Medical
'advanced' and 'op onal'. Use of basic
e q u i p m e n t e n a b l e s E M S l i n ke d
and advanced medical equipment is also
diagnosis. EMS knowledge and skills
linked to competencies and provider
become mostly useless if providers do
levels. There cannot be hard and fast rule
not have tools to help pa ents. List of
in considering certain medical equipment
medical equipment EMS providers can
i n t o o n e fi x e d c a t e g o r y. I t i s
use may be very exhaus ve.
interchangeable, based on the eco-
Ra onaliza on of equipment is
system. However, basic life support
important. There is a great need for
equipment is universally necessary.
contextualiza on of medical equipment
to the exis ng EMS system. Some mes
Standardiza on of medical equipment in
space, usage rates, benefits to the
an E M S system of reference is
pa ents and cost, influence the process
mandatory. Error reduc on and saving
of selec on. Factors like lifespan of an
me are direct advantages of
equipment, service and repair needs
standardiza on. Even lay out
must also s mulate the selec on.
standardiza on of the pa ent
Medical equipment in most of the EMS
compartment area of an ambulance will

Address for Correspondence


Dr. G.V. Ramana Rao
Director Emergency Medicine learning, Care & Research

GVK Emergency Management & Research Ins tute, Hyderabad. email: ramanarao_gv@emri.in

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 7


enhance operability of EMS staff with developed Na onal Ambulance Code
equal efficiency from any vehicle. Most of (NAC) and defined Basic and Advanced
the EMS systems discourage use of Life Support Ambulances. Basic Life
personalized equipment or treatment Support (BLS) ambulance was defined as
bags to support team-based care and a vehicle ergonomically designed,
round-the-clock du es. Single pa ent suitably equipped and appropriately
use equipment should be appropriately staffed for the transport and treatment of
disposed. Small items like masks are pa ents requiring non-invasive airway
frequently used. Some, like disposable management / basic monitoring. (Type
delivery kits are used as and when C ) . Ad van ced L ife Su p p o rt ( A L S )
needed basis. Some items are like AED ambulance was defined as a vehicle
pads are sparingly used. Some items may ergonomically designed, suitably
occupy large space like stretchers. equipped and appropriately staffed for
Hence, stock levels should also be t h e t ra n s p o r t a n d t r e a t m e n t o f
defined. emergency pa ents requiring invasive
airway management/intensive
Procurement of medical equipment is a monitoring (Type D). Code states that
challenge and hence it is necessary to general requirements of the medical
have generic specifica ons for medical devices are designed for use in mobile
equipment. Cost, u lity, availability in situa ons and in field applica ons. Word
domes c market, maintenance and 'portability' is used when an equipment is
pa ent safety are crucial issues to be expected to be mandatorily used in an
considered while procuring medical ambulance. In addi on, portability also
devices. Consistency and standardiza on takes cognisance to the ability to be
in technical specifica ons promotes carried by a person, with in- built ba ery
posi ve compe on and reduces cost. It power wherever necessary. In the
also promotes uniformity in user training ambulance portable equipment are
and smooth maintenance of equipment. generally hanged on the street wall side
of the pa ent compartment of an
Ministry of Road Transport and Highways ambulance. In certain cases, such
(MORTH), Government of India, in 2013 portable equipment can be hanged on to

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 8


the roof as well, but should reach the established under sec on 3 of the Bureau
pa ent during service. Regular and of Indian Standards Act, 1985. Where no
smooth pa ent transport equipment like relevant Standard of any medical device
stretchers and their movements should has been laid down under sub-rule (1),
not be effected by the loca on of the such device shall conform to the standard
medical equipment. Medical equipment laid down by the Interna onal
which needs to be fixed must hold the Organisa on for Standardisa on (ISO) or
d e v i c e d u r i n g a c c e l e ra o n s a n d the Interna onal Electro Technical
decelera ons including transverse, Commission (IEC), or by any other
longitudinal and ver cal movements. pharmacopoeial standards. Even the
Na onal Ambulance Code has labelling of the medical equipment
categorized the medical equipment into norms like name, details necessary for
Pa ent handling equipment, the user to iden fy the use or its uses,
immobiliza on equipment, life support details of manufacturer, quan ty, month
oxygen delivery equipment, diagnos c and year of manufacture and expiry are
equipment, infusion material, drugs, asked to be printed. In case of sterile
equipment for life threatening problems devices, date of steriliza on has to be
(Defibrillators, cardiac monitoring, given in place of manufacturing. In case
portable airway care systems, portable the device is manufactured with stable
a d va n c e d re s u s c i ta o n syste m s , material (like stainless steel), date of
ven lators), bandaging and nursing expiry need not be men oned. Unique
systems, Personal Protec ve Equipment device iden fica on number will be
(PPE), Rescue and Protec ve material, implemented in near future. Recall of a
communica on material. medical device can also happen when it
is believed to cause risk to the health of
Ministry of Health and Family Welfare user or pa ent.
(MOHFW), Government of India, extra-
ordinary gaze e, clearly indicated that Under Na onal Accredita on Board for
product standards for medical device Hospitals and Healthcare ( N A B H )
conform to the standards laid down by Providers, Access Assessment and
the Bureau of Indian Standards Con nuity of Care (AAC), it is men oned

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 9


that in hospitals availability of an ven lator (adult and paediatric &
appropriate ambulance fi ed with life- neonatal), IV cut down set / suture kit,
support facili es accompanied by trained Pulse oximeter and LMA (all sizes). ALS
personnel is a must. Under Care of ambulances only will have monitors,
Pa ents (COP), the ambulance services ven lators, fetal monitor. For each of
should be commensurate with the these medical equipment detailed
scope of the services provided by the specifica ons are lucidly documented
organiza on. It is expected that any under major headings of Name and
ambulance shall be equipped with at Coding (including defini on); General
least basic life support equipment for use; Technical (physical characters,
both adult and paediatric pa ents shall s o w a r e i f a n y, e n e r g y s o u r c e ,
be present. accessories, spares & consumables;
environmental and cleaning details;
Na onal Health Systems Resource standard and safety; training and
Centre, (NHSRC), Technical support installa on; warranty and maintenance;
ins tute of Na onal Health Mission in its documenta on- service/opera ng
technical specifica ons document listed manual; Service support/warning).
31 medical devices for emergency Equipment specific standards and safety
response ser vices for B L S / A L S such as F DA (U S-Food & Drug
ambulances. This list includes suc on Administra on), C E (European
pump (electrical/ foot operated & hand Conformity), I S O (Interna onal
operated), Laryngoscope, flow meter O rga n i za o n fo r S ta n d a rd s ) , I E C
with humidifier, oxygen cylinders (D ( I n t e r n a o n a l E l e c t r o - Te c h n i c a l
type), Bag Mask Ven la on Devices Commission) were recommended.
(adults/ children& Neonatal), Stretchers Training of users on opera on and basic
(collapsible), spinal board, double head maintenance were also proposed.
mobilizer, cervical collar, pneuma c Checking the func oning status of
splints, first aid box, Stethoscope, BP Medical equipment at the start and end
apparatus (aneroid), portable hand held of the shi is an EMS best prac ce. All
glucometer, nebulizer, foetal Doppler, ambulance staff using provided
AED, monitor, syringe pump, transport equipment should do so only if they are

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 10


adequately trained. Staff should not ambulances are expected to be audited
misuse the equipment or damage work once in a month. An essen al aspect of
equipment for their health, safety and ambulance audit is the status of medical
welfare. Line managers are to ensure equipment. An exclusively developed
that staff use work equipment and that so ware is in use in many states, in
they are trained. Asset management which EMTs can document the non-
process that records key maintenance func oning status of a medical
events throughout the opera onal life- equipment or shortage of a single use
cycle of the equipment, including device. Emergency Response Centre
commissioning, servicing, repair and Physicians during the medical direc on,
disposal are notable features in a good obtain vitals from the E M Ts, mal-
EMS organiza on. func oning or lack of medical equipment
used in pa ent assessment and diagnosis
Currently in all the RFP (Request For will be recognized on a regular basis.
Proposals) documents for ambulance Review of PCR ( prehospital care records)
services at the state level, list of the at the state level PCR Cell, assess the use
medical equipment is o en provided of right medical equipment based on the
along with specifica ons. At GVK EMRI, type and cri cality of the pa ent
medical equipment related orienta on condi on. Opera ons Execu ves are
has been a focus throughout. Medical expected to visit ambulances regularly
equipment maintenance and repair are under their jurisdic on and they
documented for the learning of Basic inevitably record the status of medical
EMTs in the form of two manuals covered equipment. In other words, training,
in founda on and refresher training monitoring and maintenance of medical
respec vely. In the two-week A L S equipment is an integral part of 108 GVK
training, medical equipment usage has EMRI. At the organiza onal level, a broad
been the focus. In exclusive A L S based annual ambulance commi ee
ambulance projects, in addi on to the reviews the equipment from me to
opera on manuals, special videos were me. AAC document lists the
developed and shared with E M Ts. e q u i p m e nt , co n s u m a b l e s , d r u g s ,
Throughout the organiza on, all the extrica on and communica on

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 11


equipment in B L S /A L S and other reflect the recogni on of exper se in the
emergency vehicles including the organiza on. Collabora on with Stanford
number to be stocked. All the equipment University and their involvement in 2-
is categorized into Essen al and year advanced E M T program and
Desirable under each type of ambulance. hospital physician program facilitated
Calibra on of medical equipment is yet development of deeper insights into the
another process in place. Call back of equipment used in life threatening and
drugs and equipment is also inbuilt or cri cal condi ons.
ac vated as and when needed. High end
equipment are put in Annual In conclusion, Indian EMS has undergone
Maintenance Contract ( A M C ). considerable standardiza on of medical
Departments of Fleet, Supply Chain equipment in the last few years. Choice of
Management and Emergency Medicine medical equipment is now an integral
Learning Centre closely coordinate the part of comprehensive care package and
study, selec on, procurement, training training. Effec ve management of this
and maintenance of medical equipment. important EMS resource is required to
Procurement of medical equipment meet the objec ve of high quality pa ent
through imports by adherence to the care, clinical and financial governance.
government laid process enables right Good medical equipment management
equipment at the right me. not only reduces the poten al harm to
Procurement of equipment in large the pa ent and the staff, but reduces
quan es across the organiza on costs. Policies and processes when in
provides much needed nego a on place and in regular control can
power. Involvement of medical teams at significantly contribute to the name and
every stage enables good quality and glory of EMS system. EMS providers
training. GVK EMRI representa ves develop immense confidence and
ge ng invited into Na onal Ambulance sa sfac on in saving lives. Well stabilized
Code (NAC) and other commi ees at pa ent along with the appropriate use of
Ministry of Health and Family Welfare medical equipment will for sure, seek
( M O H F W ) a n d M i n i st r y o f Ro a d commenda on from the receiving staff at
Transports and Highways (MORTH), the receiving hospital. Use of right

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 12


equipment in prehospital care provides 3. Policy for the Management of
excellent feedback and trust amongst Medical Devices, London
emergency pa ents and favourable Ambulance Services HHS, March
pa ent outcomes. It is a good resolu on 2017
for an EMS organiza on to orient all the 4. Construc onal and Func onal
Requirements for Road Ambulances
members on medical equipment (like
(Na onal Ambulance Code)-AIS
skilling everyone in CPR) as mandatory.
125; Department of Road Transport
A er all, medical equipment demands
and Highways, Government of India,
such high priority in EMS. Hope in the June 2013
near future, technology enables detailed
documenta on of equipment usage vis- 5. Gaze e of India, MOHFW, GOI,
à-vis type of emergency and ini ate IOT (extra ordinary) REGD. NO. D. L.-
(internet of things) to take the EMS to the 33004/99, No . 70, Part II, sec on -3,
st
next level of expecta on. sub-sec on 1, Dt 31 January 2017.

References: 6. NABH Guide Book to Accredita on


th
1. Technical Specifica ons of medical Standards for Hospitals (4 edi on)
Dec, 2015.
devices for Emergency Response
Services, Ministry of Health and
7. Technical specifica ons of Medical
Family Welfare., 2015
Devices for Emergency Response
(h p://nhsrcindia.org/category- systems, MOHFW, GOI, NSHRC,
d e t a i l / t e c h n i c a l - 2013.
specifica ons/ODgz )
8. Annual Ambulance Commi ee
2. EMS – A Prac cal Guide, Judith E. Recommenda ons, G V K E M R I,
Tin nalli, Peter Cameron, C. James 2014-15.
Holliman; People Medical
Publishing House, Shelton, 9. Medical equipment specifica ons,
Connec cut, USA- 2010. (p 253- GVKEMRI, 2014

291)
10. Manual of Medical equipment,
GVKEMRI.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 13


Original Ar cle

The Essen al Prehospital Care Refresher Course


Peter Acker 1, Danielle Mianzo1, Elizabeth Pirro a1, Ma hew C. Strehlow1, Swaminatha V. Mahadevan1

Introduc on: EMTs. To our knowledge, no prior studies


For a number of years, Stanford Emerg- had assessed the capacity of prac cing
ency Medicine Interna onal (SEMI) has EMTs in resource-poor countries to retain
partnered with G V K Emergency cri cal, life-saving knowledge and skills
Management and Research Ins tute from their inaugural prehospital care
(EMRI) to provide high quality emerg- training programs. This assessment
ency medical training to thousands of involved a wri en test designed to
health care providers, both in the pre- measure each EMT's knowledge, as well
hospital and hospital se ngs. The goal of as a hands-on prac cal skills test to assess
these emergency medicine-focused their procedural competence. Theore-
courses has been to empower health care cal knowledge was assessed through a
providers to provide expert care to their 60-ques on mul ple-choice exam tes ng
pa ents in order to save lives. While fi een essen al subjects; the exam was
Stanford University had previously validated prior to the study with American
c re a t e d c o u rs e s fo r p a ra m e d i c s , EMTs and Indian EMT instruc-tors.
physicians and EMT (Emergency Medical Clinical acumen was assessed through an
Technician) trainers, they had not been Objec ve Structural Clinical Examina on
involved in any curricula addressing the (OSCE) of nineteen vital skills. Five
educa onal needs of the roughly 10,000 examiners observed the par cipants
prac cing EMT-Basics (EMT - B). p e r fo r m i n g e a c h O S C E s k i l l a n d
determined whether they passed/ failed
Materials & Method: by u lizing a predetermined checklist.
During the summer of 2013, Stanford
University and GVK EMRI performed a The first Essen al Prehospital Care
large-scale assessment of their prac cing Refresher Training Course was taught

Address for Correspondence


Peter Acker

MD, MPH, FACEP, Clinical Assisstant Professor, Stanford University, Email: packer@stanford.edu

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 14


Acker, et, al. The Essen al Prehospital Care Refresher Course

from November 14-16, 2013, in backgrounds, including doctors and


H yd e ra b a d , A n d h ra P ra d e s h . T h e EMTs. Prior to each refresher course,
Hyderabad course instructors included Dr. these par cipants took a 30 mul ple-
S.V. Mahadevan, Dr. Peter Acker, Dr. choice ques on (MCQ) pre-test and
Danielle Mianzo, Dr. Vijay Anand, Mr. following the course, they took a 60 MCQ
Suresh Babu and Mr. Vimal Megavarnan. post-test. Their test results were entered
The course was put on with the assista- into a Red Cap database and differences
nce of the GVK EMRI Andhra Pradesh between pre- and post-test scores were
Emergency Medicine Learning Centre analyzed using the Wilcoxon signed rank
(EMLC), including Dr. G.V. Ramana Rao, sum test paired by par cipant.
who is currently the Director EMLC &
Research department. The Hyderabad Results:
refresher course par cipants included 32 Ini al assessments were performed in 3
EMT instructors from Andhra Pradesh, states – Karnataka, Gujarat, and Tamil
Tamil Nadu, Karnataka, Meghalaya, and Nadu – and included 255 prac cing EMTs.
Madhya Pradesh. All study par cipants had undergone the
GVK EMRI EMT-Basic training course at
The second Essen al Prehospital Care the onset of their career and had an
Refresher Training Course was taught average length of experience of 39
from November 22-23, 2013, in Ahmada- months in the field. The knowledge
bad, Gujarat. The Ahmadabad course assessment (wri en examina on) mean
instructors included Dr. Peter Acker, Dr. score was 47.2%(range 28-70%) for all
Danielle Mianzo and Dr. Swapneswar study par cipants. Of the fi een clinical
Sahu. The course was put on with the help skills assessed, par cipants scored
of the GVK EMRI Gujarat EMLC, including highest on prac cums pertaining to
Dr. Jayraj Desai and Ms. Meghavi Panchal. suc oning (62.1%) and oxygen
The Ahmadabad refresher course administra on (79.4%). Lowest prac cal
par cipants included 23 EMT instructors skills performance was demonstrated on
from Gujarat, Assam, Himachal Pradesh, neurovascular assessment before/a er
and Karnataka. splin ng (pass rate 2.8%), log-rolling
(5.2%), pelvic binding (6.7%), and bag-
Overall, the course par cipants were mask ven la on (6.7%).
EMT-instructors from nine states within
India and represented mixed educa onal Of the fi y-five course par cipants (EMT-

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 15


Acker, et, al. The Essen al Prehospital Care Refresher Course

instructors), fi y took both the pre- and emergency care - primarily life-saving
post-tests. For the pre-test, their mean skills, at each step in the pa ent care
score was 72.3% (SD 10.6%) and for the process: Ac va on of EMS personnel by
post-test, their mean score was 85.3% (SD the emergency call center, the ini al
9 . 6 % ) , c o r re s p o n d i n g t o a m e a n assessment and treatment of the pa ent
improvement of 13.6% (S D Δ8.3%, by the EMT, pa ent monitoring during
p<0.001). Of the thirty topic areas transport, consulta on between the EMT
assessed, par cipants showed the and call center physician, and transfer of
greatest ini al competency in cardiac the pa ent to a healthcare facility. The
monitoring (98%pre-test average), CPR resul ng Essen al Prehospital Care
(96%pre-test average), and ven la on Refresher Training Course comprised high
(92% pre-test average). The greatest quality lectures and hands-on skills
improvement was seen in extremity workshops to be delivered over a two-day
hemorrhage control (Δ +74%), OPA/NPA period (Figures 1, 2).
usage (Δ +42%), and EMS roles and
responsibili es (Δ +32%), while decreased While this ini al data suggested that the
performance occurred in documenta on inaugural refresher course was very
(Δ -18%), airway obstruc on (Δ -9%) and effec ve in addressing a number of
ven la on (Δ -5%). educa onal deficiencies, a poten al
limita on of our analysis was that the
Discussion: MCQs were not validated prior to tes ng;
This novel assessment indicated that furthermore, no control group was
many essen al concepts and cri cal pre- available against which to compare the
hospital skills were not retained by the performance of par cipants. We will also
EMTs and highlighted the need for a need to determine the reasons for the
highly focused training strategy to address decreased performance in certain subject
these deficiencies. In response to this areas.
need, during the fall of 2013, Stanford
faculty created a new EMT refresher In addi on to the pre- and post-tes ng,
course curriculum. Rather than replicate we also solicited direct feedback from the
the G V K E M R I 6-week founda on course par cipants regarding the course
training, this new curriculum focused on (Figure 3). The informa on gathered from
knowledge and skills essen al to the the course feedback forms as well as the
op mal delivery of pre-hospital MCQ tes ng has already prompted a

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 16


Acker, et, al. The Essen al Prehospital Care Refresher Course

reassessment of both pre- and post-tests, India in November, 2013. We found the
and revision of the teaching materials course was an effec ve teaching tool for
themselves, prior to their wide-scale EMT instructors leading to improvement
deployment to prac cing EMTs. in their knowledge across numerous key
prehospital care content areas. The next
Our next steps include the video taping of steps include assessment of this training
the course lectures and development of a course u lizing prac cing Indian EMTs
printed course syllabus. Subsequently, and development of other focused
trained EMT instructors will disseminate refresher training programs (e.g., medical,
the new refresher training curriculum to trauma, pediatric, obstetric).
prac cing EMTs in their home states.

900 PRE-TEST
Based on the success of the inaugural 930 EMS ROLES &
refresher course, plans are also in place to RESPONSIBILITY
develop a second refresher training (OVERVIEW)
course focused on common medical chief 945 ROUTINE
complaints, such as seizures, chest pain, MEDICAL/TRAUMA
and abdominal pain. This follow-up MANAGEMENT
(OVERVIEW)
refresher training program will be piloted
1000 PRE-ARRIVAL
in near future. The course content will
PREPARATION
again be focused on the most essen al 1015 SCENE-SIZE UP
informa on and skills that EMTs need to 1030 INITIAL ASSESSMENT
possess in order to save lives. 1045 GENERAL IMPRESSION
1100 POSITION PATIENT
Conclusion: 1115 TEA BREAK
Our novel assessment of prac cing Indian 1130 CIRCULATION
1145 AIRWAY
E M Ts during the summer of 2013
1200 BREATHING
iden fied cri cal gaps in their knowledge
1215 EXTREMITY
and skill reten on following their ini al HEMORRHAGE CONTROL
EMT training, and highlighted the need (PROCEDURE)
fo r a h i g h l y fo c u s e d e d u c a o n a l 1230 CPR (PROCEDURE)
interven on. In response, the Essen al 1245 AED (PROCEDURE)
Prehospital Care Refresher Training 100 LUNCH
Course was developed and deployed in 200 SUCTIONING
(PROCEDURE)

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 17


Acker, et, al. The Essen al Prehospital Care Refresher Course

215 MANUAL AIRWAY 1245 REASSESSMENT


MANEUVERS 100 LUNCH
(PROCEDURE)
200 COMMUNICATION
230 OPA/NPA (PROCEDURE)
245 VENTILATION 215 DOCUMENTATION
(PROCEDURE) 230 AMBULANCE
300 TEA BREAK OPERATIONS
315 PROCEDURE PRACTICE 245 LIFTING/MOVING
(HANDS-ON)
300 TEA BREAK
415 RAPID
MEDICAL/TRAUMA EXAM 315 POST-TEST
430 BASELINE VITAL SIGNS 415 TEA BREAK
445 DAY 1 OVERVIEW 430 WRAP-UP/GRADUATION
Figure 1: Essen al Prehospital Care Course, Day 1 Figure 2: Essen al Prehospital Care Course, Day 2
Overall, how
930 OXYGEN
would you rate

Excellent
Average

Good
Poor
ADMINISTRATION

Fair
the quality of
(PROCEDURE) the Stanford
Instructors?
945 CARDIAC MONITORING
(PROCEDURE) The level of Strongly disagree

Strongly agree
the medical
Disagree
1000 IV ACCESS (PROCEDURE)

Neutral

Agree
information
1015 GLUCOSE CHECK discussed is
(PROCEDURE) appropriate

1030 MEDICATION
Strongly disagree

Strongly agree
ADMINISTRATION The lecture
Disagree

Neutral

Agree

(PROCEDURE) topics are


helpful
1045 NEBULIZATION
(PROCEDURE)
1100 FLUID Overall, how
Excellent
Average

would you rate


Good
Poor

Fair

ADMINSTRATION(PROCE the quality of the


lectures
DURE)
1115 TEA BREAK
Overall, how
would you rate
Excellent
Average

1130 PROCEDURE PRACTICE


Good
Poor

the quality of the


Fair

(HANDS-ON) practical skills


sessions?
1230 HISTORY

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 18


Acker, et, al. The Essen al Prehospital Care Refresher Course

Strongly disagree
· Overall my favorite part of the

Strongly agree
I would like to

Disagree
course was (please list specifics):

Neutral
watch a video of

Agree
the lectures · How will the content of these
again.
sessions be helpful to you
(CIRCLE all that apply)?
A. To increase my personal
Strongly disagree
I would

Strongly agree
recommend a Disagree
knowledge
Neutral

Agree
similar course
to a B. To provide improved pa ent
peer/colleague. care
C. To improve my teaching of
I believe these EMT students
Strongly disagree

Strongly agree
sessions will D. I am unsure of the
Disagree

Neutral

Agree

allow me to
educate EMT's
usefulness
more effectively E. It will be useful in other ways
in the future. (please describe below)
My level of · What topics addressed today
Some Knowledge

knowledge were unclear, please list


Knowledgeable
No knowledge

about these specifically:


Beginner

Expert

emergency
medicine topics · Please make any other
BEFORE the comments to help improve the
course was: course here:
My level of Figure3: Essen al Prehospital Care
Some Knowledge

knowledge Refresher Course Feedback Form


Knowledgeable
No knowledge

about these
Beginner

Expert

emergency
medicine topics
AFTER the
course was:
Excellent

Overall how
Average

Good
Poor

Fair

would you rate


the course?

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 19


Original Ar cle

Effec veness of CBR Training on ASHA Workers


Authors: Ankita Brahmaroutu1, Purva Rajendra2, Rajini Danthala3, GV. Ramana Rao4
Abstract

Introduc on: The ASHA (Accredited Social Health Ac vist) worker program was set up by India's Ministry
of Health and Family Welfare in 2005. The goal of the program was to bridge the gap between ci zens in
rural areas of India to the health facili es that they may need, specifically with women's health, neonatal
care, and hygiene. According to the Memorandum of Understanding (MoU) between District Medical
Health Office (DMHO)- Rangareddy District and GVK EMRI on 8th August, 2012, 100 ASHA workers from
the Shameerpet & Medchal Mandal were trained in the Community Based Resuscita on (CBR)
Programme; it was a 01 day programme. The main objec ve of the programme was to train the ASHA
workers in Basic life Support (BLS), normal delivery, and recogni on of emergencies and management.

Objec ves: The main objec ves of this study were to iden fy the usefulness of CBR training in service
delivery by ASHA workers, obstacles in applying the skills, and determine the need if any, for future
training.

Methodology: The study used both qualita ve and semi-quan ta ve methods: Focus Group Discussion
(FGD) & telephonic interviews through stra fied random sampling. Telephonic interview were
conducted using semi-structured ques onnaire prepared in light of the findings of the FGD. Quan ta ve
Data Analysis using Microso Excel was an appropriate method to determine the degree of the impact.

Results: FGD was conducted for 09 ASHA workers, and the remaining 91 ASHA workers were interviewed
over phone. Out of 91 members, we received a response from 52 members. The age group range of
par cipants in the study was 35-48 years, majority (57%) had passed SSC & Backward Class (OBC)
category. 55% of par cipants said common emergencies in their area of work are related to pregnancy.
90% of ASHA workers called 108 in emergency situa ons. 90% of ASHA workers said the CBR training was
excellent. 62% of them used it in conduc ng deliveries, 12% in pregnancy-related emergency handling.

Discussion: From the CBR training, ASHA workers u lized the advantage of some life-saving skills and the

Address for Correspondence


Ms. Ankita Brahmaroutu

Address: 3237 Bay Hill Lane, Round Rock, TX, USA 78705, Mail ID: ankitavb@utexas.edu,
Contact number: 512-983-8006

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 20


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

training has improved their confidence level to perform more effec vely in villages. Their increased social
recogni on from their ability to perform as an ASHA worker has led to some health improvement in rural
India. Most of them are sa sfied by the work they were doing, but need proper resources and financial
support to con nue health improvement in their village.

Conclusion: ASHA workers are in constant contact with the rural people of their village, especially
pregnant women. The CBR program was effec ve and helpful in emergency cases, because it was more
skill-oriented than other trainings ASHA workers had experienced. The CBR training has made the ASHA
workers psychologically feel be er about the work they were doing.

Key words: Community-Based Resuscita on (CBR) Programme, ASHA worker, Rural area, Pregnancy-
related emergencies, Delivery, Immuniza on

Title: Effec veness of CBR Training on ASHA Workers

Introduc on
The ASHA (Accredited Social Health Ac vist) worker program was set up by India's Ministry of

Health and Family Welfare in 2005 by the is an example to what an ASHA worker's
Na onal Rural Health Commission (NRHC) role in her village is. The current training for
specifically. The goal of the program was to ASHA workers include being able to
bridge the gap between ci zens in rural communicate between rural area pa ents
areas of India to the health facili es that and hospitals, developing a health plan that
they may need, specifically with women's includes sanita on efforts, working fluently
health, neonatal care, and hygiene. “Along with other healthcare workers in villages,
with Nurse didi, the Anganwadi behen, Self counseling pa ents, ensure that pa ents
Help Group (SHG) members and the male receive the right help, treat simple illnesses
Mul Purpose Workers (MPW), you will such as colds, dispensing the right vitamins,
have some assignments to do in the village, and maintaining records. Since ASHA
like water disinfec on, or a ending the workers interact with pregnant women at
Antenatal Care (ANC) clinic/health day1.” every stage, Community Based
This quote, from Book Number 1 for Resuscita on (CBR) training includes
training the ASHA workers wri en by the useful and necessary skills to have.
Na onal Health Systems Resource Center
(NHSRC), states the beginning skills that The CBR training that was conducted at
rd th
ASHA workers are expected to master and GVK EMRI on August 23 and 24 of 2012.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 21


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

It included 100 par cipants from the on A S H A workers concerning their


Rangareddy and Shamirpet mandal. The performance, reten on, and the health
training included: learning to escort o u t c o m e s o f t h e i r c o m m u n i t y. A
pa ents to the hospital before, during, and comprehensive study done at Columbia
immediately a er child birth, controlling University in 2011 concludes that the
difficul es during pregnancy and child impact of the ASHA worker program all lies
birth, resuscita ons for every age, mal on the ASHA workers individually, and a er
presenta ons (shoulder dystocia and qualita ve and quan ta ve data, it was
breech), and Postpartum hemorrhage2. It found that ASHA workers are not mee ng
has been about 11 months since the their responsibili es. They cannot
training, and the Focus Group Discussion ar culate what their specific roles are in
(FGD) and telephonic interview of research their community, and some did not
3
project evaluated the reten on and complete their training .
usefulness of this training for future plans
regarding ASHA worker training. The In an evalua ve study done in Seth GS
reason the FGD method was considered Medical College and KEM Hospital in India
the best method for conduc ng the i n 2 0 1 2 r e g a r d i n g A S H A w o r ke r s
evalua on of the CBR training was because knowledge reten on, it was found that the
an FGD provides depth into a par cular trainings that ASHA workers experienced
issue, which a survey cannot do. It allows was not enough for them to remember
par cipants to agree and disagree with months later. It was suggested that periodic
each other and can accurately represent a refreshers should be done, and “In the
popula on. Opinions, beliefs, rela onships future training sessions, more emphasis
between ideas, and feedback can all be should be given to high risk cases requiring
explored in a FGD. We were not able to prompt referral 4 .” C B R training was
perform FGD for all, so for remaining ASHA specifically designed to train ASHA workers
w o r ke rs , t h e y w e r e e v a l u a t e d b y in emergency situa ons in hopes of
telephonic interview. Evalua ng the CBR broadening their range of skills.
training's impact can best be done by
receiving input from the par cipants in a In a study evalua ng the ASHA workers in
meaningful and in-depth manner through Karnataka in 2012 however, the ASHA
an FGD. workers were found to be opera onal in
the three villages studied and the
Literature Review conclusion was that, “Special training of
There have been quite a few studies done ASHAs should be undertaken since one of

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 22


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

the primary objec ves of the ASHA The FGD method was the best method for
5
programme is to improve social jus ce .” this study. A FGD does not discriminate
Social jus ce may include preventa ve based on people who can read or write.
measures for infec ous diseases and Considering many of the ASHA workers
assis ng pa ents in mes of dire need, have li le educa on, it is best to talk in
such as deliveries. The CBR training is a person with them. These workers may also
special training for emergency situa ons, feel uncomfortable with a one-on-one
and could improve the quality of life in rural interview and thus will not be able to speak
areas of India. their mind. A focus group eliminates that
element, and introduces a more
Studies have been conducted using the comfortable environment with a group of
FGD method on ASHA workers as well. The par cipants who are all very similar to one
World Bank in Washington D.C. in 2012 had another. A study that provides some
an objec ve of studying the performance evidence to these claims was wri en in
mo va on of community health workers, 1995 by researchers at the University of
and how it affected the ASHA program. Glasgow. “A method that facilitates the
Using surveys and F G Ds, the study expression of cri cism and the explora on
concluded that “the CHW programme of different types of solu ons is invaluable
could mo vate and empower local lay if the aim of research is to improve
women on community health largely. The services7.”Since the objec ves of this study
desire to gain social recogni on, a sense of is to determine the need, if any, for future
social responsibility and self-efficacy training and assess the knowledge and
mo vated them to perform.” However, impact of CBR training on ASHA workers,
there needs to be more amendments kept there needs to be a way to receive honest
in place to make sure the proper training opinions. The FGD is a method that
and supervision is met6. This study displays “facilitates the expression of cri cism.” If
the important aspect of mo va on. If it has there is cri cism regarding the CBR
been proven that community health training, the trainings can be modified and
workers have the desire to do well in improved for future ASHA worker classes.
society, then the FGD that was conducted
over the CBR training focused on the ASHA
workers knowledge and applica on, and Ra onale
there will be less doubt as to whether or ASHA workers play a crucial role in the
not the training competence was due to wellbeing of rural areas of India. They are
lack of interest in the workers. one of the few types of healthcare workers

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 23


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

that provide trained assistance for Research ques on


pregnancies, women's health, and How has CBR training benefi ed ASHA
emergency cases. The CBR training is workers?
necessary for ASHA workers; it includes
cri cal life-saving techniques that help Objec ves
solve common emergency situa ons, such • To assess the usefulness of CBR
as CPR for adults and newborns, normal training in service delivery by
delivery prac ce, shoulder dystocia, ASHA workers.
maternal resuscita on, PPH, and mal • To assess the A S H A workers
presenta ons. As quoted from MoU knowledge gained from the CBR
between DMHO-RR and GVK EMRI on 8th training.
August, 2012:“CBR course is expected to • To determine the need if any, for
upgrade the ASHA workers skills as per the future training.
recent expert recommenda ons…Increase • To iden fy any obstacles in
the confidence among ASHA workers by applying resuscita on skills.
enhancing the life support skills while
accompanying the pregnant women en- Methodology
route to ins tu onal delivery…Benefit the The study uses both qualita ve and semi-
community by increasing access to the quan ta ve methods. To make the study
quality of care under NRHM…Assist other sta s cally competent inclusion of more
healthcare provider more efficiently.” than 9 ASHA workers as subjects had
These points illustrate why CBR was an become impera ve in order to study the
essen al training for the ASHA workers. benefits of CBR training which was given to
Equipped with the knowledge gained in this 100 ASHA workers in total. Out of 100
training, ASHA workers have the ability to ASHA workers who received CBR training 9
assist a larger variety of pa ents, and par cipants were selected for Focus Group
ensure the safety of mothers and their Discussion through stra fied random
children. An assessment of the CBR sampling. 6 par cipants were selected
training and its usefulness is necessary and randomly from the Rangareddy mandal
important to understand, as it indicates and 3 from the Shamirpet mandal based on
how the healthcare in rural areas of India is the propor on of them who received
changing, and what future plans need to be training from these mandals.
implemented to con nue to improve the
healthcare in rural India. The FGD was arranged in a board room in
GVK EMRI Campus. The par cipants were

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 24


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

assigned a number that only the objec ves through enumera on and
8
researchers were aware of, to make it tables .
easier to iden fy the par cipants. There
was a voice and video recorder during the Through the opinions of the par cipants
en re session, and there was a moderator, and their ability to correctly explain the
as well as a guide to the moderator to keep procedures done in various case scenarios,
the moderator on track. Addi onally, 2 a conclusion was made as to what kind of
observers were in the room (people who impact the CBR training had in the rural
understand the study and either communi es of the ASHA workers. The
understood Telugu or read the facial tone of the conversa on will be noted, and
expressions and body language of the any comments that trigger an emo onal
par cipants). These observers were response from other par cipants will be
assigned general topics to analyze during analyzed as well.
the session, such as “tone of the
par cipants” or “emo onal responses of CBR training conducted in GVK EMRI was
the par cipants.” Please refer to Appendix given to a sample of 100 ASHA workers.
A for more informa on over the researcher Since the FGD covered a group of 9 of these
roles and a complete list of topics the ASHA workers, telephonic interviews were
observers were assigned. Appendix B conducted with an inten on to include all
displays the ques ons to be asked to the the 100 ASHA workers, as to increase the
par cipants. At the beginning of the strength of the study.
discussion, the study was explained to the
par cipants; a form (Appendix C) with basic On calling the remaining ASHA workers for
informa on about the par cipant was telephonic interview, 52 of the 91
signed, indica ng consent. A script of the responded. The telephonic interview was
beginning and end as to be told by the conducted using semi-structured
moderator is wri en in Appendix D. ques onnaire prepared in light of the
findings of the FGD.
The means of analyzing the data was
through a Qualita ve Data Analysis. This Quan ta ve Data Analysis using Microso
method included transcribing the en re Excel was an appropriate method to
session, categorizing every statement into determine the degree of the impact. The
a code: concern, knowledge, and analysis included looking for trends and
responsibility, then further categorizing unexpected responses in the commentary
these codes into rela ons with the and telephonic conversa ons.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 25


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

3% 3%
The ASHA workers were all very engaged
8%
in the discussion, and they par cipated
SSC pass
ac vely. Table 2 displays a summary of
High school educa on
Intermediate pass the points discussed for each of the
28% 57%
2 yrs undergraduate ques ons asked to the par cipants. At
Graduate
the end, the ASHA workers seemed
sa sfied and eager to help with the study.
Fig.1: Educa onal Status of Par cipants (n=61) There were about 3 domina ng
Findings and Results: p a r c i p a n t s , b u t t h e m o d e ra t o r
The age group range of par cipants in the managed to recieve a few important
study was 35-48 years. words from the quieter par cipants as
well.
Table 2: Discussion Points in FGD
Educa on Status: The educa onal status
Sl. No Facilitator Answer from participant
of par cipants of both the Focus Group Question
Discussion and the telephonic interview
1. How has - Antenatal check-up
is depicted in Figure 1. your work - Immunization
as an ASHA - Emergency situation
assistance
All the par cipants had 8 years of worker been
- Record maintenance
involvement in the A S H A worker so far?
- Educates villagers about
program. In terms of educa on, out of 61 health, family planning, and
par cipants, a majority (57%) had passed 108 usage
- Calls 108 in most cases for
SSC, while 28% received high school the patient
educa on less than SSC. 8% of them were - Distributing tablets
Intermediate pass, 3% had undergone 2 - Active role play a role in
DOT program
years of undergraduate educa on, and
the remaining 3% were graduates. 2. Let's talk 1. Spots on the patient's skin;
about some she had never seen that
emergency kind of snake bite before.
The methodology followed for further situations She immediately called
analysis of findings from FGD and you have 108 and made sure the
been in. patient's skin condition did
telephonic inter view is “Parallel
What not get worse. The patient
Synthesis” wherein both are analyzed happened made a full recovery.
independently and parallel to each other. and how did
you handle 2. Patient experiencing chest
it? pains. She advised the

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 26


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

patient to sit down and not


4. What was - Our condence, skill set ,
have anything until the
your per for mance level has
ambulance came. The
experience increased
patient did not listen to her,
had the tea, and expired en before and - Ever yone in the village
after the CBR star ted recognizing and
route to the hospital due to
training? respecting us
heart attack.
- Our ability to react to
emergency situations has
3. Drunken man falling from
improved
a building. He was
- We need to have more
b l e e d i n g a n d
resources to help our
unconscious. The ASHA
villagers like rst aid kit,
worker used rst aid
basic medications etc…
procedures and called
108. She did not have Imagine a - Clean the baby and keep him
5.
enough resources like situation warm with a towel
cotton and gauge-roll to where you - Rub the back & Flick the sole
give the rst aid. Despite - Check the skin color
conduct a
the ASHA worker's
delivery and - Check the breathing and pulse
objections the wife of the
the newborn - Do the chest compressions
patient insisted she take with two ngers or thumb
is not crying.
her husband to the encircle if required.
What would
hospital by means of auto
rickshaw before the you do?
ambulance arrival. The 6. A 22-year-old - Call the attenders
patient died en route to the female - Ask the victim whether her
hospital. patient of water has broken or not
- BLS Protocol: Check the unknown - Ask whether she is having
3. Knowledge
response by shake and duration of back pain or feels fetal
about CBR
shout; Check the breathing, pregnancy movements
training complains of - Dial 108, and we educate
Check the carotid pulse, If
Pulse is absent, Chest abdominal women to call 108 in case of
compressions with two pain. What to emergency on their own
hands in adult and with two do? - After CBR training we are
ngers for babies. able to Manage/conduct
deliveries with condence.
- Ratio is 30 compressions
and 2 ventilations 7. How do you - We will ask the medical
feel about history like - Have had this
- Procedures for choking
treating Post case many times, -Ask how
- Procedure to conduct a frequently they are changing
partum
normal delivery pads, since how long she is
hemorrhage;
- We gain a good amount of having this problem, &
share your
knowledge from CBR Observe the victim how much
experience if sick she is because of
training but there is very less
any? bleeding.
scope for us to practice it in
real scenarios. - Call 108 if urgent.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 27


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

A er going through the list of ques ons expected to do more than assist pa ents
and ge ng feedback from everyone, the to the hospital and treat simple illnesses.
en re session was transcribed. Along They are becoming the “li le doctors” of
with the thema c analysis of the session, the villages, as stated by several workers
the notes taken from the moderator and during the FGD. By increasing their skill
two observers were recorded and set and knowledge, they can become
analyzed as well. Every comment was more helpful to pa ents in diverse
categorized into a type of answer, such as emergency situa ons.
“knowledge, skills” or “complaints.” From
Table 3: Findings of FGD
that data, the types of comments were

Sl. No
then narrowed down into a more broad Objective: Summery

code. The three codes represented a To assess the - T h e C B R t r a i n i n g w a s


1.
theme in rela on to the objec ves: to usefulness of effective to ASHA workers
assess the usefulness of CBR training in CBR training because it gave them more
in service condence with handling
service delivery by ASHA workers, to
delivery by pregnant women
assess the ASHA workers knowledge
ASHA
gained from the C B R training, to workers - Created a better relationship
determine the need if any, for future between ASHA workers and
training, to iden fy any obstacles in the villagers and other
health workers in the village
applying resuscita on skills. The codes
by improving knowledge &
were: co n cern s, kn owled ge, an d communication skills
responsibility. From each code, a
2. To assess the - Remembered the basic
summary and statement was made
ASHA topics covered
concerning both the research ques on workers - Could handle the situations
and applicable objec ves. The list is knowledge asked, but have not had the
found in Table 3. Judging by the gained from experience
the CBR - Do not use many of the
par cipants' non-verbal cues, many
training techniques they have
workers did not seem sa sfied with their
learned, such as dealing
wo r k . O n l y a few A S H A wo r ke rs with PPH, and its
dominated the conversa on, while the prevention
others either agreed or sat silently. It
seems that there needs to be much more
support for the ASHA workers in terms of
their ability to help. They seem to be

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 28


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

3. 2%
To determine - M a y n o t n e e d m o r e
the need if emergency training, But
any, for they want to have a OBC
42%
future knowledge in recognition SC
56% ST
training of a real emergency.
- Requesting for a refresher
programme once in a year
- Their needs are in the Fig.2 Social Status of Participants (n=52)

areas of supplies and Out of a total of 52 par cipants, a


nancial suppor t from majority 56% belong to Other Backward
Government
Class (OBC) category, 42% belong to
- Wanted more training in
premature births, Scheduled Caste, and 2% belong to
Dysmenorrhea Scheduled Tribes.
management, and what
to do about various body Common emergencies in work area:
pains W h e n a s ke d a b o u t t h e c o m m o n
4.
emergencies which they come across on
To identify - Less chance to practice what
any obstacles we have learned in CBR
a daily basis, ASHA workers' response
in applying training, it creates Lack of was depicted in Figure 3:
resuscitation experience. Common EM work area
skills - Lack of supplies for 2%
Pregnancy & related EM
4% 2%
management of deliveries or
Fever & infec ous disease
bleeding. 13% cases
Accident & Injury cases
- Lack of general resources
Heart a ack
availability like cotton, gauge 55%
25%
roll, betadine etc.. Snake bite

Anemia
Findings of Telephonic Interview: Fig.3 Common Emergencies in area of work (n=52)
Social status: At the me of FGD social As shown in Figure 3, 55% said common
status was not directly asked to the emergencies in their area of work are
par cipants to avoid any level of related to pregnancy, 25% said they are
discomfort caused by it. The social status fever and infec ous disease cases, 13%
of par cipants in telephonic interview is said accident and injury cases are most
depicted in the figure.2: common, while 4% iden fied most
common emergency as heart a ack. Very
few (2%) men oned snake bite and
anemia, respec vely.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 29


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

Response in Emergency situa ons: 90% Experience of CBR training

On facing emergency situa ons when


asked about their response, the reac ons 9%
1%
of ASHA workers are as depicted in Figure
Excellent Good Fair
4:
Fig. 5 Experience of CBR training (n=52)
Response to emergency situations

Out of 52 ASHA workers, 90% said that


2.30%
2.30%
2.30%
2.30%

Called 108

Gave CPR in no pulse


the C B R training experience was
cases
Chest Compressions Excellent, 9% said it was good, and a
Tried to manage pa ent
& refer to hospital
remaining 1% said it was fair. No ASHA
90%

Educate the pt & refer to


hospital worker responded in nega ve sense to
Fig.4 Response in Emergency situa ons (n=52) the experience.
As shown in Figure 4, 90% of ASHA
workers called 108 in emergency Perceived use of CBR Training:
situa ons. 2.3% each of the remaining When asked if the CBR training had been
ASHA workers said they gave cardio- put to use, 26 of the 52 ASHA (50%)
pulmonary resuscita on in no pulse workers responded that they have used
cases, gave chest compressions, and tried the CBR training in some way or the
to manage or educate the pa ent and other. Their responses are as depicted in
refer to hospital. Figure 6:
Pu ng CBR training in use
Conduc ng Deliveries
When asked how o en they used 108 4% Helping Nurses in care
4% 4%
training, out of total 52 ASHA workers, 8%
Managing SOB case

about 38% said regularly, while 62% said 8%


Giving First Aid

rarely. 62% In cordprolapse case


12%
Giving reassurance to pt

Experience of CBR Training: When asked Bleeding control

Fig.6 Pu ng CBR training in use (n=26)


to the ASHA workers about how they Fig.6 Putting CBR training in use (n=26)

found the CBR training, they responded


As shown in Figure 6, out of total 26 ASHA
as depicted in Figure 5:
workers who had put the training in use
some way or the other, 62% said they had
used it while conduc ng deliveries, 12%

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 30


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

said while helping Sister in the hospital, Effect on service delivery a er CBR training
13%
8% said in handling a case with a 21%
Improved care to ANC
breathing problem, 8% said for giving first 11% CASES
Improvement in basic
service provided
aid, 4% used it in cord pro-lapse case, Be er deliveries
conducted
giving reassurance to the pa ent, and Confidence level
increased
bleeding control, respec vely. 55%

Fig.8 Effect on service delivery a er CBR training (n=52)


Aspects of CBR training put in use: As men oned in Figure 8, 55% said there
When asked for what purpose they have is an improvement in basic services
used CBR training, 15 ASHA workers said provided, 21% said they provide be er
they have used it for recogni on of care to ANC cases, 13% said be er and
emergency, 7 said they have used it for safer deliveries have been conducted,
giving medical advice, 16 ASHA workers and the remaining 11% said that their
said for management of emergency, and confidence level has increased.
the remaining 15 said for provision of
care as depicted in Figure 7. Need for be er care: When asked to the
Aspects of CBR training used ASHA workers about what services they
35% 31%
30% 29%
21% need to provide be er care for, their
25% responses were recorded in Figure 9.
20%
13%
Proper health facility with More medical equipment inMore training on pregnancy Room to examine pregnant

15%
10%
pa ent

5%
3%

0%
Medical advice Recogni on of Management of Providing Care
Required improvement for be er care

emergency emergency
related emergency handling

Fig.9 Services needed to provide be er care (n=32)

Fig.7: Aspects of CBR training used (n=52)


13%

Effect on service delivery a er CBR


training: When asked to the ASHA
our ki

workers if there has been any change in


6%

the service they give to their beneficiaries


availability of doctors at night

a er the CBR training was conducted,


their response was as depicted in
78%

Figure 8.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 31


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

As men oned in Figure 9, 25 workers said As shown in Figure 10, when asked about
they need proper health facili es with what feedback their beneficiaries gave
availability of doctors at night, 2 needed about their service, 45% ASHA workers
more medical equipment in their kit, 4 said they received good feedback, 32%
said they need more training on said they got feedback as fair, and the
pregnancy-related emergency handling, remaining 23% said they had excellent
and 1 said she needs a room to examine feedback. When asked if they would
pregnant pa ent. recommend C B R training to their
colleagues, 50 ASHA workers said they
Feedback from pa ent about ASHA would while 1 did not respond to the
workers: ques on.
Neonatal and child Dog and snake bite Infec ous diseases

When asked for any sugges ons for CBR


training, the response of the ASHA
Mngt
2%

workers was as follows:

As shown in Figure 11, out of a total of 42


Mngt
2%

ASHA workers who responded to this


ques on, 15 said they should be taught to
Fig.11 Sugges ons for CBR training
administra on emergencies Mngt

give an injec on, another 15 responded


Sugges ons for CBR training
36%

they feel the need for training on


neonatal and childhood emergencies, 7
responded that they should be taught to
Medica on

take blood pressure, 3 said that the


36%

training should be of a longer dura on,


while the remaining 1% each responded
Vitals assesment

that there should be training on dog and


17%

snake bite management, and training on


diseases like pneumonia.
Dura on should
be increased
7%

Conclusion
No.of ASHA Workers
From the findings of FGD and telephonic
interview men oned above, it can be
concluded that CBR training has not

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 32


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

necessarily helped ASHA workers to handle emergency situa ons. Since the
conduct more deliveries, but it was a training 11 months ago, the 9 ASHA
training that ASHA workers said made workers in the FGD study had not u lized
them more comfortable and confident in the CBR training skills. Even in PPH cases,
assis ng pregnant women and which they see a lot, they are not able to
maintaining a rela onship with them. help much, except change pads on a
The CBR training has definitely improved regular basis and send the pa ent to the
the knowledge and effec veness of the hospital. The par cipants also said that
ASHA program, as interpreted from the compare to other trainings they have
ASHA workers answers to the telephonic been to, the CBR training is be er,
interviews. This was one of the objec ves because it is more skill-oriented. Despite
of the MoU. The prac cal aspect of CBR the par cipants compliments for the
was greatly appreciated. The points program and their assurance that the
shown in Table 3 and Figure 4 conclude C B R training has made them feel
that ASHA workers are doing be er at psychologically be er, it was show
iden fying and assis ng in emergency through the PPH ques on that the ASHA
situa ons, advising pa ents, and first aid workers are not u lizing their skills.
measures. This is displayed especially
through the emergency situa ons the The future work of this study should focus
par cipants described, and their ability more on the weaknesses in the ASHA
to safely and effec vely handle a program. The weakness lies in the
hypothe cal emergency situa on. inability for ASHA workers to help in their
full extent due to a lack of supplies and
ASHA workers are in constant contact money. The improvements do not
with pregnant women, and the chance of necessarily lie in training, but giving more
an emergency situa on arising is high. supplies to ASHA workers so that they
The villagers and ASHAs have to have a have the means to help villagers in case of
strong and trus ng connec on for the emergency. It was men oned by mainly
A S H A worker program to remain all the par cipants that even if they had
effec ve and be helpful in emergency to conduct a delivery, they have a
cases. Now, the par cipants are not as shortage of the supplies. If there is a weak
scared to go to villagers' homes and assist link between the government, ASHA
them. They now know they are equipped workers, and the villagers, the healthcare
with a general understanding of how to in rural areas cannot improve greatly.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 33


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

ASHA workers also said that reverse References


transporta on is another huge issue, as
the hospital does not bring the pa ent 1. Hota, P. Reading Material for
back in most cases, and ASHA workers ASHA. Na onal Rural Health
Mission; 2005.
have to pay out of their own pocket for a
way to bring pa ents back home. There 2. Author Unknown. Community
should be a method to follow up on Based Resuscita on Programme
reverse transporta on and make sure Report. GVK EMRI. 2012.
that there is a sufficient amount of
3. Bajpai, N, Dholakia R. Improving
supplies. Once the weaknesses are
the Performance of Accredited
restored, there can be more of a focus on Social Health Ac vists in India.
strengthening the ASHA training and Columbia Global Centers. 2011.
finding a way for the ASHA workers to
implement their knowledge (perhaps 4. Shrivastava S, Shrivastava
P.Evalua on of trained Accredited
through yearly refresher trainings). Also,
Social Health Ac vist (ASHA)
the par cipants men oned that if they workers regarding their
were to have another training, they knowledge, a tude and prac ces
would want to know more about how to about child health.Rural Remote
deal with various body pains (specifically Health. 2012; (4).
h p://www.ncbi.nlm.nih.gov/pub
menstrual cycle pains) and premature
med/23198703. [2013 Jul 20].
births. These areas, along with reverse
transporta on, the major complaint by 5. Mony P, Raju M. Evalua on of
ASHA workers about a lack of supplies, ASHA programme in Karnataka
and an increasing amount of mistrust in under the Na onal Rural Health
Mission. BMC Proc. 2012; (6).
the community between villagers and
h p://www.ncbi.nlm.nih.gov/pmc
ASHA workers, are areas to be further /ar cles/PMC3467467/. [2013 Jul
researched and developed. Overall, the 20].
CBR training was useful for the ASHA
workers, but training is not necessarily 6. Gopalan, S. Mohanty, S. Das, A.
Assessing community health
the next logical step. Firstly, the focus on
workers' performance mo va on:
financial support and confidence- a mixed-methods approach on
building for ASHA workers should be India's Accredited Social Health
addressed, and then new emergency Ac vists (ASHA) programme.BMJ
training programs should be developed. Open. 2012; (5).

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 34


Brahmaroutu et, al. Effec veness of CBR Training on ASHA Workers

h p://www.ncbi.nlm.nih.gov/pub
med/23019208. [2013 Jul 20].
7. Kitzinger, J. Qualita ve Research.
Introducing Study Groups. BMJ.
1995; 311(7000): 299-302.
h p://www.ncbi.nlm.nih.gov/pmc
/ar cles/PMC2550365/. [2013 Jul
20].

8. Johnson. Qualita ve Data Analysis.


<www.southalabama.edu/coe/bse
t/johnson/lectures/lec17.pdf?>.
[2013 Jul 20].

9. www.emri.in

10. Community Based Resuscita on


Training manual and final report by
GVKEMRI.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 35


Original Ar cle

Do all Poster abstract presenta ons get due recogni on


and publica ons compared to oral presenta ons?
Kumara V. Nibhanipudi

Introduc on: their supplement to Annals of EM


There are 2 types of abstract without prejudice or discrimina on.
presenta ons, namely oral and Poster
Presenta ons. Oral presenta ons Methods:
compared to poster cost nothing. Poster Inclusion Criteria:
presenta ons cost money paid by either Those physicians who are willing to
the par cipant or the department. The par cipate in the unanimous survey with
par cipants take same amount of me no iden fiers.
and effort for both types of .
presenta ons. The other significant Methodology:
important differences between oral and It is an anonymous physicians survey
poster presenta ons is the audience study. No iden fiers. This survey is with
recep ve/responsiveness behavior. Most regards to poster versus oral abstract
of the organizers as well as endorsing presenta ons. All the physicians( both
na onal academies will publish only few a ending and residents) were requested
oral presenta ons and no poster to answer the survey ques onnaire by
presenta ons. To the best of my circling their preference of choice.
k n ow l e d ge , A m e r i ca n C o l l e ge o f
Emergency Physicians (ACEP) is the only Survey ques onnaire:
Na onal Emergency Medicine (EM) 1. Are you a ending or resident.
organiza on compared to the rest, 2. How do you like your abstract
publishes all accepted abstract presenta on:
presenta ons both oral and posters in oral only

Address for Correspondence


Kumara V. Nibhanipudi,
MD, FAAP, FAAEM

Prof. of Clinical Emergency Medicine, NYMC & A ending Physician, Metropolitan Hosp, Ctr, NY

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 36


Nibhanipudi. et, al. Do all Poster abstract presenta ons get due recogni on and publica ons compared to
oral presenta ons?

poster only as well on invited guest speakers


No preference either poster or oral Agree
3. Recogni on and responsive nature disagree
by Organizers as well as by physician somewhat agree.
a endees: with due recogni on and Results:
apprecia on for the poster survey 1: #of par cipants: 100
presenta ons: a ending Physicians.
Agree For Survey 2: 100/100 no preference-
Disagree circled for either oral or poster.
Somewhat agree For Survey 3: 100/100 circled
4. All accepted abstracts both oral and somewhat agree.
poster presenta ons to be published. For Survey 4: 100/100 all circled
Source of funds, if needed to be agree.
i n c u r re d fo r p u b l i ca o n a s a
supplement in a journal can be
realized either from the collected
registra on fees and/or from total
elimina on or minimizing wastage
expenses on conference organizers
Table: Survey ques onnaire:
Circled answers Prefer Prefer Oral No preference Recognition and #4 publication of all
Poster presentations Either Oral responsive nature by abstracts (both oral &
Presentations only or poster Organizers as well as by poster) as a Supplement
only presentations physician attendees: to a journal and nances
with due recognition and to be reimbursed either
appreciation for the from collected
poster presentations: registration fees and/or
funds to be collected
from minimizing
expenditure spent on
organizers as well as
invited guest speakers.

agree 0 0 100/100 0 100/100


disagree 0 0 0 0 0

Somewhat agree 0 0 0 100/100

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 37


Nibhanipudi. et, al. Do all Poster abstract presenta ons get due recogni on and publica ons compared to
oral presenta ons?
Graph depic ng the survey abstracts were presented between 2007
ques onnaire and 2012. Of these 390 presenta ons
graph depic ng the result of Survey Ques onnaire were oral and the remaining 932
presenta ons were poster. 19% of these
100 100 100
100 were subsequently published in PEER
Numbers

50 reviewed journals. The percentage of


000 0 0 0 00 00 0 0
0 publica ons for oral was 28% and posters
R

2
LY
LY

P.
YS

were 15% results1


TE

EX
ON
ON

PH
OS

SE
ER
AL

&
/P

EA
G
ST
OR

AL

OR

CR
PO

OR

DE
BY

&

Na onal orthopedic mee ngs are used to


N

ON
IO
IT

I
AT
GN

disseminate current research through


IC
CO

BL
RE

PU

podium and poster abstract


Axis Title
agree disagree somewhat agree
presenta ons. Not all of these abstracts
go on to full-text journal publica on.
Sta s cs: According to William et al in their
We used In Silico, Fisher exact test determined the publica on rates of
comparing survey results of agree, podium and poster presenta ons from
disagree and somewhat agree the the American Orthopedic Foot & Ankle
resultant p-value is <0.0001. Society ( A O FA S ) annual mee ngs
between 2008 and 2012.
Discussion:
According to Levinsky and others less Podium abstracts were significantly more
than half of the abstracts presented at likely to be published compared to
the Pediatric Academic Society (PAS) posters. The AOFAS overall full-text
mee ng were published within 8 years. journal publica on rate was one of the
Oral presenta ons were more likely to be higher reported rates compared with
1
published than poster other na onal orthopedic society
mee ngs, which have ranged from 34%
According to Yolcu and Ozcan, in their to 73%. Overall full-text publica on rate
study to find out the rate of peer was 73.7% for podium presenta ons and
reviewed publica on of full papers of 55.8% for posters. Podium presenta ons
abstracts at the annual mee ng of the were published in a journal significantly
Oral and Maxillo Facial (OMF) Surgery more o en than posters3.
Society of Turkey. A total of 1322

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 38


Nibhanipudi. et, al. Do all Poster abstract presenta ons get due recogni on and publica ons compared to
oral presenta ons?

Akash Patel and others studied to repor ng is be er in oral abstracts than


determine the publica on rates of both in poster abstracts at the American Burn
oral and poster presenta ons at Congress Associa on (ABA) conference mee ngs.
of Neurological Surgeons (CNS) and All 511 abstracts from the ABA annual
American Associa on of Neurological mee ng from 2000 to 2008 were
Surgeons (AANS) mee ngs in peer- screened. However they concluded that
reviewed journals. The authors reviewed there is no difference between oral and
all accepted abstracts, presented as poster presenta ons, as far as the quality
either oral or poster presenta ons, at the of study design and quality of clinical
CNS and AANS mee ngs from 2003 to trials.5
2005. This informa on was then used to
search PubMed to determine the rate of Uzun and his co-authors hypothesized
publica on of the abstracts presented at that the full-text publica on of abstracts
the mee ngs. Abstracts were considered presented at any given scien fic mee ng
published if the data presented at the in peer-reviewed journals is accepted as a
mee ng was iden cal to that in the measure of scien fic quality of that
publica on. par cular mee ng. They tried to
determine the full-text publica on rate of
The overall publica on rate was 32.48% abstracts presented at the 2005 Scien fic
(1243 of 3827 abstracts). On average, Mee ng of the Undersea and Hyperbaric
41.28% of oral presenta ons and 29.03% Medical Society (UHMS). Overall, they
of poster presenta ons were eventually iden fied 187 abstracts presented at the
published. Approximately one-third of all 2005 UHMS mee ng and found that only
presenta ons at the annual CNS and one-third of the abstracts presented at
AANS mee ngs will be published in peer- the 2005 UHMS mee ng were published
reviewed, MEDLINE-indexed journals. as full-text ar cles within the succeeding
Oral presenta ons have a significantly five years6
higher rate of eventual publica on
4
compared with poster presenta ons . As per Chan and his colleague that The
publica on rate of full text papers
Karsten and his colleagues were of the following an abstract presenta on at a
opinion, that the quality of oral and medical conference is variable, and few
poster conference presenta ons differ. studies have examined the situa on with
They hypothesized that the quality of respect to interna onal emergency

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 39


Nibhanipudi. et, al. Do all Poster abstract presenta ons get due recogni on and publica ons compared to
oral presenta ons?

medicine conferences. This retrospec ve presented at the PAS mee ng achieved


study aimed to iden fy the publica on subsequent full publica on within 4 to 5
rate of abstracts presented at the 2006 years. There were no meaningful
Interna onal Conference on Emergency differences between the presenta on
Medicine (ICEM) held in Halifax, Canada. formats in their mean me to publica on
The full text publica on rate was 33.2%, and their mean journal impact factor.
similar to previous emergency medicine Their study is inconclusive regarding
mee ngs. English language barriers may superiority of one form of presenta on
8
play a role in the low publica on rate compared to the other
seen7.
Conclusions:
See comment in PubMed Commons From our survey study for abstract
belowCarroll and other co-authors presenta ons, the mode of presenta on
ques oned The validity of research does not ma er either oral or poster;
p re s e n t e d a t s c i e n fi c m e e n g s secondly there is somewhat agreement
con nues to be a concern. Presenta ons regarding recogni on and recep ve
are chosen on the basis of submi ed nature from both by the organizers and
abstracts, which may not contain physician a endees. All definitely agree
sufficient informa on to assess the for publica on in the journal of all
validity of the research. The objec ve of abstract publica ons both oral and
this study was to determine 1) the posters without any discrimina on and
propor on of abstracts presented at the funds to be reimbursed either from
annual Pediatric Academic Society (PAS) collected registra on fees and /or
mee ng that were ul mately published realizing funds derived from minimizing
in peer reviewed journals; 2) whether the expenditure spending on organizers as
presenta on format of abstracts at the well as invited guest faculty
mee ng predicts subsequent full
publica on; Limita ons:
Smaller sample size
They assembled a list of all abstracts
submi ed to the PAS mee ngs in general
pediatrics categories in 1998 and 1999,
using both C D - R O M and journal
publica ons. Overall, 44.6% of abstracts

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 40


Nibhanipudi. et, al. Do all Poster abstract presenta ons get due recogni on and publica ons compared to
oral presenta ons?

References: Neurological Surgeons Journal of


Neurosurgery Dec 2011 / Vol. 115 /
1,2 1,2 1,2
1. Levinsky Y , Berger T , Brameli A , No. 6 / Pages 1258-1261
1,2 1
Goldstein T , Akerman E , Mimouni
M3, Mimouni FB4, Amarilyo Gs 5. Karsten Knobloch1 Uzung Yoon2,
Publica on outcomes of Hans O Rennekampff1 and Peter M
neonatology abstracts presented at Vo g t 1 – Q u a l i t y o f r e p o r n g
the Pediatric Academic Socie es according to the CONSORT, STROBE
mee ng and Timmer instrument at the
J Perinatol. 2017 Apr 6. doi: American Burn Associa on (ABA)
10.1038/jp.2017.46. [Epub ahead of annual mee ngs 2000 and 2008
print]) BMC Medical Research
Methodology201111:161 D O I :
2. Ozcan A2.Publica on rates in peer- 10.1186/1471-2288-11-161)
reviewed journals of abstracts 1
presented at the Oral and 6. Uzun G , Mutluoğlu M, Bakir A,
Maxillofacial Surgery Society of Senocak MS. 1Fate of abstracts
presented at the annual scien fic
Turkey mee ngs 2007-2012. 2015
mee ng of the Undersea and
Nov;53(9):849-53. doi:
Hyperbaric Medical
10.1016/j.bjoms.2015.07.005. Epub
Society.1Undersea Hyperb Med.
2015 Jul 30. 2013 Sep-Oct;40(5):387-93
1 2 2
3. Williams BR , Kunas GC , Deland JT , 7. Chan JW 1 , Graham CAFull text
2
Ellis S J .Publica ons Rates for publica on rates of studies
Podium and Poster Presenta ons presented at an interna onal
from the American Orthopaedic emergency medicine scien fic
Foot & Ankle Society. Foot Ankle Int. mee ng Emerg Med J. 2011
2017 Jan1:1071100716688723. doi: Sep;28(9):802-3. doi:
10.1177/1071100716688723 10.1136/emj.2010.101667. Epub
2010 Sep 15.
4. Akash J. Patel, M.D.*, Jacob Cherian,
M.D., Benjamin D. Fox, M.D., William 8.
1
Carroll AE , Sox CM, Tarini BA,
E. Whitehead, M.D., M.P.H., Daniel J. Ringold S, Christakis DA
Curry, M.D., Thomas G. Luerssen, Pediatrics..Does presenta on
M . D. , a n d A n d rew J e a , M . D. format at the Pediatric Academic
Publica on pa erns of oral and Socie es' annual mee ng predict
poster presenta ons at the annual subsequent publica on?Pediatrics.
m e e n g s o f t h e C o n g re s s o f 2003 Dec;112(6 Pt 1):1238-41.
Neurological Surgeons and the
American Associa on of

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 41


CASE STUDY

Paraphimosis
Kumara V. Nibhanipudi

This is a 5 yrs old, un-circumcised male Plan:


child has come for a complaint of penile Apply EMLA(Eutec c Mixture of Local
swelling for 3 days; no fever. no complains Anesthe cs) cream over the glans penis
of dysuria, or hematuria. no vomi ng. No and over the sha of penis and pa ent
diarrhea; The mother tried to retract the was observed 45 minutes for EMLA
foreskin and unable to pull back to its cream to take effect. The reduc on was
normal posi on. 3 days back. On exam: no accomplished as follows: the thumbs of
sign of distress. no signs of meningeal both hands were placed on the glans
irrita on. Chest: clear. No wheezing. penis and fingers wrapped behind the
Abdomen: non tender. No masses. No prepuce. A gentle forceful pressure was
organomegaly. External Genitalia: applied to the glans with the thumbs and
prepubertal. Tanner I; Both Testes are counter-trac on was applied to the
descended and Penis: diffuse swelling over foreskin with the fingers as prepuce was
the sha of the penis and swelling over the pulled down and the en re foreskin got
glans; slightly erythematous; no warmth; covered over the glans as in Figure # 2.
and ght constric on band as seen in
Figure # 1;

Address for Correspondence


Kumara V. Nibhanipudi,

Prof. of Clinical Emergency Medicine, NYMC & A ending Physician, Metropolitan Hosp, Ctr, NY

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 42


Nibhanipudi : Paraphimosis

Figure # 1 Figure # 2
Tight constric on band with edema of foreskin Post reduc on paraphimosis with foreskin over the glans
No regional lymphadenopathy. Rest of the PE
unremarkable.
Imp: Paraphimosia

Discussion: edematous distal to the constric on


Paraphimosis is a real urosurgical band and can palpate the ght
emergency and present in constric on band. If the glans or
uncircumscised males. Paraphimosis is prepuce appears to be black, auto-
an inability of the foreskin to return to necrosis has begun, and if it feels non
its normal posi on a er it is pulled elas c with areas of discolora on,
behind the glans penis. Hayashi and his penile necrosis should be suspected.
colleagues described that the
paraphymosis is a condi on in which In the management of paraphimosis
1
the foreskin is le retracted the pain is the predominant factor. The
usual management of pain is by using a
The most common cause of combina on of dorsal penile and ring
paraphimosis is iatrogenic, following blocks or by applying EMLA cream to
Foley catheter placement, forceful the edematous foreskin and over the
retrac on of the foreskin as in our constric ve band and awai ng for an
2
pa ent, self-inflicted injury, or rarely hour , or usage of hyaluranidase
secondary to penile erec ons. The injec on over the edematous foreskin3.
pa ent is apprehensive, complains of Lastly, Using ice and osmo c agents
p e n i l e p a i n , p e n i l e fo r e s k i n i s might take 1-2 hours to have an

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 43


Nibhanipudi : Paraphimosis

effect and should not be used when elderly men. Am J Emerg Med. 1995
arterial compromise is suspected, May;13(3):351-3).
Regardless of the method chosen,
when In our pa ent we applied EMLA
cream over the en re edematous
foreskin and over the constric ng band
and waited for an hour. Reduc on is
applied as described in our
management. The other method of
reduc on of paraphimosis is surgical
4
emergency dorsal slit . Later on the
ul mate management for successful
reduc on of paraphimosis is
circumcision.

References:
1 ( Hayashi Y1, Kojima Y, Mizuno
K K o h r i K P re p u c e : p h i m o s i s ,
paraphimosis, and circumcision
Scien ficWorldJournal. 2011 Feb
3 ; 1 1 : 2 8 9 - 3 0 1 . d o i :
10.1100/tsw.2011.31)

2. Axel S. Merseburger, Markus A.


Kuczyk, Judd W. Moul - 2014 -
Urology at a Glance - Page 362 –
usage of 2% lidocaine gel or EMLA
cream Ax Google Books
Resulth ps://books.google.com/bo
oks?isbn=36425485982.

3. (Li le B1, White M.Treatment


op ons for paraphimosis. Int J Clin
Pract. 2005 May;59(5):5913.)

4. ( W i l l i a m s J C M o r r i s o n
PMRichardson Paraphimosis in

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 44


REVIEW ARTICLE

Good Samaritan Law


Dr. G.V. Ramana Rao

Ro a d A c c i d e n t a n d S u s t a i n a b l e provides a powerful focus to galvanize


Development Goal : governments and the interna onal
Every one minute one road traffic community into ac on on road safety
accident (RTA) occurs in India and one policy. World Health Organiza on Report
fatal road accident occurs every fourth on prehospital trauma care systems has
minute. Nearly 480,000 R TAs and categorically stated that “Even the most
150,000 deaths were reported in the year sophis cated and well equipped pre-
2016 in India. Though, the number of hospital trauma care systems can do li le
road accidents decreased, number of if bystanders fail to recognize the
deaths, in fact, increased over the earlier seriousness of a situa on, call for help,
years. But, the 2030 Agenda for and provide basic care un l help arrives.
Sustainable Development Goals (SDG- Bystanders must feel both empowered to
3.6 and 11.2) includes an ambi ous act, and confident that they will not suffer
target to reduce road traffic deaths and adverse consequences, such as legal
injuries by 50% by 2020. It is hoped that liability, as a result of aiding someone
this target will leverage renewed w h o h a s b e e n i n j u r e d .” H e n c e ,
momentum for the Decade of Ac on for involvement of bystanders is a must in
Road Safety 2011–2020. If s ll today the context of reduc on of Indian Road
some 1.25 million people die from road Traffic Accident related deaths.
traffic crashes every year at the global
level, and millions more are injured, it is Introduc on to Good Samaritan Laws:
because policy makers par cularly those G o o d S a m a r i ta n l aws o ffe r l e ga l
in low and middle income countries protec on to people who give
con nue to find road safety solu ons out reasonable assistance to those who are,
of reach. Global policy framework or who they believe to be injured, ill, in

Address for Correspondence


Dr. G.V. Ramana Rao
Director Emergency Medicine learning, Care & Research

GVK Emergency Management & Research Ins tute, Hyderabad. email: ramanarao_gv@emri.in

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 45


Dr. G.V. Ramana Rao, Good Samaritan Law

peril or otherwise incapacitated. In health services. Only first aid provided


essence, these laws protect the “Good without inten on of reward or financial
Samaritan” from liability if unintended compensa on is covered in Good
consequences result from their Samaritan Law. Medical professionals are
assistance. Its purpose is to keep people t y p i ca l l y n o t p ro te c te d b y g o o d
from being reluctant to help a stranger in Samaritan laws when performing first aid
need for fear of legal repercussions in connec on with their employment.
should they make some mistake in
treatment. Bystanders and impediments to help
RTA vic ms:
Good Samaritan laws take their name A study on impediments for bystander
from a parable found in Bible, a ributed care in India, conducted by TNS India
to Jesus referred to as the “Parable of the Private Ltd. for SaveLIFE Founda on(July-
Good Samaritan” which is contained in 2013).The study covered various
Luke 10:25-37. It recounts the aid given categories of bystanders and poten al
by a traveller from the area known as Good Samaritans across seven ci es of
'Samaria'to another traveller of a India to develop a first-hand account of
conflic ng religious and ethnic factors that hinder bystanders from
background who had been beaten and coming forth as first responders to assist
robbed by bandits. a seriously injured vic m on the road.

Duty to assist, imminent peril and


The survey was carried out among 1,027
reward or compensa on, obliga on to
road-users across Delhi, Hyderabad,
remain and consent are the common
Kanpur, Ludhiana, Mumbai, Indore and
features of Good Samaritan Law. The
Kolkata.
furnishing of medical assistance in an
emergency is a ma er of vital concern
affec ng the public health, safety and Within each loca on the survey was
welfare. Prehospital emergency medical conducted at busy city intersec ons as
care, the provision of prompt and well as along highway stretches leading
effec ve communica on among to the city.
ambulances and hospitals to safe,
effec ve care and transporta on of the Three broad categories of respondents
sick and injured are essen al public

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 46


Dr. G.V. Ramana Rao, Good Samaritan Law

were covered during this survey, viz. had to, they are more likely to help a
Pedestrians, vehicle owners and patrons vic m of road accident than of violence.
at roadside establishments.
88% respondents expressed the need for
Major findings of the study: a suppor ve legal environment to enable
74% of bystanders are unlikely to assist a Good Samaritans to come forward and
vic m of serious injury irrespec ve of help injured vic ms on the road.
whether they are alone at the spot or in
the presence of others regardless of 38% of all bystanders feel that bystander
whether there were others on scene or responsibility ends with calling the
not. emergency numbers.

88% of respondents who were unlikely to 77% respondents are aware of which
assist injured vic ms stated that they emergency numbers to call to report an
were reluctant to help for fear of legal accident.
hassles, including repeated police
ques oning and court appearances. In a landmark ruling on March 4, 2016,
Supreme Court stated that it would pass
77% of respondents who were unlikely to an order on the recommenda ons of a
assist injured vic ms also stated that three-member commi ee, chaired by its
hospitals unnecessarily detain Good former Judge K.S. Radha Krishnan and
Samaritans and refuse treatment if comprising former Secretary of Road
money is not paid for treatment. Transport Ministry S. Sundar and scien st
Nishi Mi al, which had demanded
78% of respondents belonging to the protec on for those saving accident
lowest socioeconomic bracket (probably vic ms. Chronology towards Good
the poorest people on the road) are Samaritan Law in India are as follows:
unlikely to come forward to assist a
vic m. 72% of middle income and 70% of I. 2012: Public Interest Li ga on (PIL)
upper-income respondents stated that filed by SaveLIFE Founda on.
they would not come forward to help the
injured vic ms. ii. October 29, 2014: The Supreme
Court directed the Centre to issue the
58% respondents admi ed that if they necessary guidelines with regard to the

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 47


Dr. G.V. Ramana Rao, Good Samaritan Law

protec on of Good Samaritans un l discrimina on on the grounds of gender,


appropriate legisla on was not made by religion, na onality and caste.
the Union Legislature.
2. A n y i n d i v i d u a l , e x c e p t a n
eyewitness, who calls the police to inform
iii. M a y 1 3 , 2 0 1 5 : I n a g a z e e them of an accidental injury or death
no fica on, Ministry of Road Transport need not reveal his or her personal details
and Highways (MoRTH) no fied the said such as full name, address or phone
guidelines. As per the guidelines, the number.
disclosure of personal informa on by a
Good Samaritan who brings an injured 3. The police will not compel the Good
person to the hospital was made Samaritan to disclose his or her name,
voluntary. They also provided that a Good iden ty, address and other such details in
Samaritan would not be liable for any civil the police record form or log register.
or criminal liability.
4. The police will not force any Good
iv. January 22, 2016: MoRTH issued Samaritan in procuring informa on or
Standard Opera ng Procedures (SOPs) anything else.
for the examina on of Good Samaritans
by the police or during trial. 5. The police will allow the Good
Samaritan to leave a er having provided
v. March 4, 2016: The Supreme Court the informa on available to him or her,
reserved the judgment making the and no further ques ons will be asked of
guidelines and SOPs binding on all states him or her if he or she does not desire to
and union territories of India. be a witness.

vi. March 30, 2016: The Supreme Court Even when Good Samaritans agree to
approved the guidelines issued by the become witnesses, the guidelines accord
Centre. them protec on and comfort. They
ensure that:
The guidelines lay down the following:
1. If a Good Samaritan chooses to be a
1. The Good Samaritan will be treated witness, she will be examined with
respec ully and without any utmost care and respect.

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 48


Dr. G.V. Ramana Rao, Good Samaritan Law

2. The examina on will be conducted Central Government considers it


at a me and place of the Good necessary to protect the Good
Samaritan's convenience and the Samaritans from harassment on the
inves ga on officer will be dressed in ac ons being taken by them to save the
plain clothes. life of the road accident vic ms and,
therefore, the Central Government
3. If the Good Samaritan is required by hereby issues the following guidelines to
the inves ga on officer to visit the police be followed by hospitals, police and all
sta on, the reasons for the requirement other authori es for the protec on of
shall be recorded by the officer in wri ng. Good Samaritans, namely, :-

4. In a police sta on, the Good (1) A bystander or good Samaritan


Samaritan will be examined in a single including an eyewitness of a road
examina on in a reasonable and me- accident may take an injured person to
bound manner, without causing any the nearest hospital, and the bystander
undue delay. or good Samaritan should be allowed to
leave immediately except a er furnishing
5. If a Good Samaritan declares himself address by the eyewitness only and no
to be an eyewitness, she will be allowed ques on shall be asked to such bystander
to give her evidence in the form of an or good Samaritan.
affidavit.
(2) The bystander or good Samaritan shall
The guidelines also specify that the be suitably rewarded or compensated to
concerned Superintendent or Deputy encourage other ci zens to come
Commissioner of Police are responsible forward to help the road. accident vic ms
in ensuring that all the above-men oned by the authori es in the manner as may
procedures are implemented throughout be specified by the State Governments.
their respec ve jurisdic ons.
(3) The bystander or Good Samaritan
Extraordinary Gaze e No fica on No. shall not be legally responsible for any
126, published by the authority of civil and criminal liability.
Government of India, on May 13th 2015,
highlights that: (4) A bystander or good Samaritan, who

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 49


Dr. G.V. Ramana Rao, Good Samaritan Law

makes a phone call to inform the police or either be by way of a commission under
emergency services for the person lying sec on 284, of the Code of Criminal
injured on the road, shall not be Procedure 1973 or formally on affidavit
compelled to reveal his name and as per sec on 296, of the said Code and
personal details on thephone or in StandardOpera ng Procedures shall be
person. developed within a period of thirty days
from the date when this no fica on is
(5) The disclosure of personal issued.
informa on, such as name and contact
details of the good Samaritan shall be (9) Video conferencing may be used
made voluntary and op onal including in extensively during examina on of
the Medico Legal Case (MLC) Form bystander or good Samaritan including
provided by hospitals. the persons referred to in guideline (1)
above, who are eye witnesses in order to
(6) The disciplinary or departmental prevent harassment and inconvenience
ac on shall be ini ated by the to good Samaritans.
Government concerned against public
officials who coerce or in midate a (10) The Ministry of Health and Family
bystander or good Samaritan for Welfare shall issue guidelines sta ng that
revealing his name or personal details. all registered public and private hospitals
are not to detain bystander or Good
(7) In case a bystander or good Samaritan, Samaritan or demand payment for
who has voluntarily stated that he is also registra on and admission costs, unless
an eye witness to the accident and is the good Samaritan is a family member or
required to be examined for the purposes rela ve of the injured and the injured is to
of inves ga on by the police or during be treated immediately in pursuance of
the trial, such bystander or good the order of the Hon'ble Supreme Court
Samaritan shall be examined on a single in Pt. Parmanand Katara vs Union of India
occasion and the State Government shall & Ors [1989] 4 sec 286.
develop standard opera ng procedures
to ensure that bystander or good (11) Lack of response by a doctor in an
Samaritan is not harassed or in midated. emergency situa on pertaining to road
accidents, where he is expected to
(8) The methods of examina on may provide care, shall cons tute

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 50


Dr. G.V. Ramana Rao, Good Samaritan Law

"Professional Misconduct", under of these guidelines appropriate ac on


Chapter 7 of the Indian Medical Council shall be taken by the concerned
(Professional Conduct, E que e and authori es.
Ethics) Regula on, 2002 and disciplinary
ac on shall be taken against such doctor (15) A le er containing these guidelines
under Chapter 8 of the said regula ons. shall be issued by the Central
Government and the State Government
12) All hospitals shall publish a charter in to all Hospitals and Ins tutes under their
Hindi, English and the vernacular respec ve jurisdic on, enclosing a
language of the State or Union territory at Gaze e copy of this no fica on and
their entrance to the effect that they shall ensure compliance and the Ministry of
not detain bystander or good Samaritan Health and Family Welfare and Ministry
or ask deposi ng money from them for of Road Transport and Highways shall
the treatment of a vic m. publish adver sements in all na onal
and one regional newspaper including
(13) Incase a bystander or good electronic media informing the general
Samaritan so desires, the hospital shall public of these guidelines.
provide an acknowledgement to such
good Samaritan, confirming that an The above guidelines in rela on to
injured person was brought to the p ro tec o n o f bysta n d er o r go o d
hospital and the me and place of Samaritan are without prejudice to the
suchoccurrence and the liability of the driver of a motor vehicle in
acknowledgement may be prepared in a the road accident, as specified under
standard format by the State sec on t 34 of the Motor Vehicles Act.
Government and 1988 (59 of 1988:).

disseminated to all hospitals in the State Though the law is applicable all across,
for incen vising the bystander or good Karnataka State was the first state to pass
Samaritan as deemed fit by the State the bill in Legisla ve Assembly (2016)
Government. with a tle Good Samaritan and Medical
professional (protec on and regula on
(14) All public and private hospitals shall during emergency) where in defini on of
implement these guidelines immediately Good Samaritan used was a person who,
and in case of noncompliance or viola on in good faith, without expecta on of

Indian Emergency Journal / Vol-IX / Issue-I / April 2018 51


Dr. G.V. Ramana Rao, Good Samaritan Law

reward and without any duty of care or lawsite.ca/goodsamaritan.htm


special rela onship, voluntarily comes
forward to administer emergency care to 4. h p : / / w w w . g o o d s a m a r i t
an injured person. In addi on, protec on anday.org/info/kit.pdf
for good Samaritan from civil and
criminal liability; Rights of Good 5. h p://savelifefounda on.org/gsl-
Samaritan; establishment of Good microsite/
Samaritan Fund; educa onal ins tu ons
to impart training on first aid and 6. Save LIVES - A road safety technical
emergency to students; organiza on of package. Geneva: World Health
awareness programs and work shops Organiza on; 2017. Licence: CC BY-
were also clearly men oned. In addi on, NC-SA 3.0 IGO.
no person shall detain a Good Samaritan
for any purpose in a hospital where such 7. Study on Impediments to Bystander
Good Samaritan has brought the injured Care in India, © SaveLIFE Founda on;
person, in accordance with the rights July 2013
granted under the act.
8. WHO Report tled “Prehospital
In conclusion, Good Samaritan Law is an Trauma Care Systems, 2005.
important milestone in India, through
which, ci zens can help the road traffic 9. The Gaze e of India, Extraordinary,
vic ms and persons in emergency May 13, 2015, Ministry of Road
without any fear and seek sa sfac on of Transport and Highways.
giving back to the society.
10. Legisla ve Assembly Bill 35 of 2016,
th th
Karnataka, 14 LA and 12 session.
1. Road Accident Report 2016-
Ministry of Road Transport and
Highways, GOI

2. h p s : / / e n . w i k i p e d i a . o r g
/wiki/Good_Samaritan_law

3. h p://www.canadian

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