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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 143-148

“First responder” bike ambulance service in India: An innovative concept by the provider end


1 Department of Community Medicine, Sri Devraj Urs Medical College, Kolar, Karnataka, India
2 Department of CFM, AIIMS, Patna, Bihar, India
3 Public Health Division, RMRC, Bhubaneswar, Odisha, India

Date of Submission22-Feb-2021
Date of Decision16-Apr-2021
Date of Acceptance24-Jun-2021
Date of Web Publication04-Mar-2022

Correspondence Address:
Bijaya Nanda Naik
Department of CFM, AIIMS, Patna - 801 507, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_28_21

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  Abstract 


Most of the deaths due to road traffic injuries occur outside the hospital. However, the trauma care system in India is still in the nascent stage to provide emergency prehospital health-care services. The emergency prehospital trauma health-care services are mostly limited to the urban areas in India. The heavy traffic in urban areas, adverse topography, poor health infrastructure, and unavailability of skilled human resources in the rural areas limit the provision of prehospital trauma care services in India by using traditional car ambulance. The bike ambulance service and the first responder seems to complement each other to provide prehospital emergency trauma care services in the every corner of India negotiating the constraints faced by car ambulance services. The bike ambulance service has been started in few cities across few states/union territories in India, but it has a long way to go. Inadequate public funding, lack of guidelines, and skilled workforce form the bottle neck in rolling out of bike ambulance services across India. The government can take the opportunity of the services of vast network of nongovernmental organizations (NGO), self-help groups, youth clubs, and other social organizations to make this initiative an exemplary solution for providing optimum prehospital emergency trauma care services.

Keywords: Bike ambulance, emergency health care, prehospital trauma care, road traffic injury, trauma


How to cite this article:
Reddy MM, Naik BN, Selvaraj K, Kanungo S, Verma M, Ramalingam A. “First responder” bike ambulance service in India: An innovative concept by the provider end. CHRISMED J Health Res 2021;8:143-8

How to cite this URL:
Reddy MM, Naik BN, Selvaraj K, Kanungo S, Verma M, Ramalingam A. “First responder” bike ambulance service in India: An innovative concept by the provider end. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:143-8. Available from: https://www.cjhr.org/text.asp?2021/8/3/143/339049




  Introduction Top


Injuries are a major public health problem, accounting for 10% of global burden of diseases.[1],[2] Globally, 1.3 million people die and 20–50 million people suffer nonfatal injuries every year due to road traffic accidents.[3] The estimates by the World Health Organization in 2004 showed that nearly 50% of all road traffic fatalities occur at the site of the crash or on the way to hospital.[4] For every death that occurs in the hospital due to injury, there are about 15–20 seriously injured patients needing hospitalization and about 30–50 injured patients needing first-aid care in the community.[5]

In the backdrop of “Decade of Action for Road Safety: 2011–2020” by United Nation, emergency health-care services become indispensable to avoid deaths and disability due to road traffic injuries (RTIs). The prehospital services form an integral part in the provision of emergency health care services for injured persons. The prehospital health care has also been recognized and advocated by the WHO to reduce morbidity and mortality due to injuries.[6] The target 3.4 of Sustainable Development Goal also envisages reduction of preventable deaths due to RTI to half by 2020. To reduce the preventable deaths due to RTI on national highway, the Government of India has developed a 4-tier trauma framework to provide tier specific health-care services to trauma victims which includes emergency and definitive care services.[7]


  Emergency Trauma Care Services and “Golden Hour” Top


Access to prompt and quality medical assistance is vital in saving life in emergency situations. Prehospital trauma care services which form the initial point of emergency trauma care, vary widely and depend on the availability of infrastructures, resources, and trained personnel.[8] As a country moves from preindustrial era to industrial, developed, and urbanized era, the expected number of accidents and death increases.[9],[10] Majority of the deaths due to accidents occur before the patient can reach the hospital.[11],[12] Nearly half of the trauma deaths occur within the 1st hour of accident and another 30% within 24 hours of arrival at a hospital.[13]

The critical element is getting the first aid/medical help at the earliest. Delay or not attaining the patient during prehospital time leads to failure of resuscitation or poorly maintained airway or continuing hemorrhage.[8] According to a study by Henry and Reingold, prehospital trauma care provides considerable benefits to the affected patients in developing nations. It is recommended that developing nations should adopt a prehospital trauma care system at the policy level.[14] In developing countries like India, a considerable number of people do not adopt road safety measures including safe driving practices.[15] Most of the developing and under developed countries lack the adequate infrastructure and trained health personnel (doctors) to provide institution-based definitive trauma care.

Prehospital health-care services (first aid measures at the scene and transit time) greatly influence the outcome of RTI. The most important factor that influences the outcome is time taken to get health-care attention.[16],[17],[18],[19],[20],[21] In developing countries, severely injured patients who are transferred directly to definitive trauma care have better outcomes.[22] Although majority of the road trauma victims are able to reach hospital or get assistance during golden hour in urban India, it is not so in case of rural areas.[15] Car ambulance services used for emergency service mostly lack qualified personnel and functional equipment.[23] Hence, a significant number of patients are not able to reach the hospital within “golden hour.”

“Golden Hour” rule in trauma care defines it as “Getting the right patient to the right place at the right time.”[8],[24] In general, golden hour refers to the 1st h following the occurrence of injury.[16] It has been found that if the patient reaches the trauma care facility within this golden hour, the survival rate increases significantly.[8] Applicability of this concept is debatable in developing countries like India, where infrastructure, resources, and transport are in disarray more so in the rural and remote areas.[25]

Although limited, literature from India also advocates for reduction in the time taken to get prehospital care to improve the outcomes of RTI victims. A study from Puducherry revealed that only 21% of the RTI patients reached the health-care facility within the golden hour.[26] Another study from Mumbai also reported delayed arrival of RTI victims at the health facility.[27] The delay encompassed the time spent in referral centers and to travel the distance to reach center providing definitive care.

Hence, the priorities in emergency medical care services are the accessibility of the patient to first aid care at the earliest and shifting the patient to the centers where more definitive health care can be provided. This is possible through the implementation of robust prehospital trauma care services. A meta-analysis has shown substantial reduction in morbidity and mortality in low- and middle-income countries (LMICs) after the implementation of prehospital trauma care services.[28]

Emergency trauma care

The emergency health-care delivery system is required for acute health conditions such as injury. The emergency trauma care services provided through emergency health-care delivery system are grouped into two parts:

  1. Hospital (emergency department) trauma care: More of definitive care
  2. Prehospital trauma care: More of stabilization and initial health care.


Prehospital trauma care

The prehospital trauma care services are provided at the site of scene and till the injured person reaches the hospital/health care facility. The prehospital care includes accessibility, rapid transportation, and deployment of personnel with basic life support (BLS) skills and triage. The prehospital trauma care process consists of six steps[8] [Figure 1].
Figure 1: Six steps of prehospital trauma care

Click here to view


The prehospital trauma care has been suggested at three levels depending upon the availability of resources and trained personnel.[8]

  1. First responder care


    1. Provided by mostly nonmedical persons (by standers, policemen, laypersons, and community volunteers) who are trained in first aid care
    2. Actions expected: Call for help, provide first aid care and assist in providing first aid care, assessing seriousness of injury and help in transportation.


  2. Basic prehospital trauma care


    1. Provided by community members or paramedics who have formal training in prehospital BLS
    2. Actions involved: Scene management, rescue, stabilization, and transportation of injured person to facility with definitive care


  3. Advanced prehospital trauma care


    1. Provided by highly skilled medical personnel or paramedics
    2. Actions involved: Intravenous fluid, endotracheal intubation, highly skilled intervention like needle decompression and cricothyroidotomy.


    Prehospital emergency medical services vary from country to country, even across different parts of a particular country, between the states/regions. It is of two types: Uniform and Tiered.[13],[29] Depending upon the resources, workforce and transport facility, different countries adopt any one of the two types of emergency medical system.

    Uniform: Always send the advanced life support (ALS) unit for providing care.

    In this system, trained paramedics/sometimes doctor accompany the ambulance to the scene for prehospital care before the patient is shifted to hospital.

    Tiered: Initially send the BLS unit/first responder or ALS unit depending upon type of emergency and severity of victims.

    1. First tier:


      1. lay people, community volunteer as first responder
      2. trained in first aid care
      3. provide care, clear airway, stop the bleeding before the ambulance/paramedics comes.


    2. Second tier


      1. Paramedics
      2. Trained in BLS system.


Considering infrastructure, resource and workforce constraint, tiered type prehospital emergency medical services seem to be most apt for the developing and under-developed countries. “Stay and play” (stabilize the victim at the scene and wait for the medical/paramedical team to come and take over) and “Scoop and Run” (transport the injured persons immediately to the nearest trauma care facility without waiting for the medical/paramedical personnel to arrive) are the two strategies which can be adopted to provide prehospital trauma care. The strategy to be adopted depends upon the distance from the definitive health service provider, seriousness of injury, and availability of prehospital trauma care resources.

Emergency prehospital trauma care in India

India is one of the first among the LMICsto have widespread Emergency Medical Services (EMS). Recently, the government and various private players have developed prehospital emergency trauma care services.[13],[30] The prehospital trauma care responsibility lies with the hospital owned ambulance services or government funded 108 and 102 services, with the bulk of the responsibilities lying with the later.


  Challenges for Current Prehospital Trauma Care and Four-Wheeler Ambulance Services in India Top


The prehospital trauma care services in LMIC like India face constraint in providing adequate timely patient care and spatial coverage.[31] Emergency car ambulance services are in poor shape in India. Accessibility is the major drawback of the traditional ambulance services. More than half of the population in India live in areas without formal EMS car ambulance system. A study from South India has reported <10% of the accident patients being brought to the hospital by ambulances.[25] Lack of stringent traffic rules, poor transport facilities, inadequate logistics, and trained human resources weaken the prehospital trauma care services.[32],[33],[34] Urban development and mis-management of traffic further affects the timely arrival of traditional emergency services to the rescue of the victims. Most of the victims are transported to trauma care centers/hospitals by bystanders or taxis without first aid being given.[35] The judiciary process also prevents the passer-by to help such accident victims. The recent Supreme Court judgment, Good Samaritan law offers legal protection to people who come forward for help of accident victims by protecting them from harassment of police, hospitals, and other authorities.[36] Most of the ambulances are not accompanied by health personnel (doctor/emergency care provider), rather by the ambulance driver and an attendant who are not training in basic emergency care.

Need for bike ambulance service in developing countries like India

Literature has proven the association between dispatch time and on-scene time with the probability of mortality.[37],[38],[39] Dispatch time is the time required to reach the victim after getting the call and on-scene time is the time spent with the victim before sending him to the trauma center.

For long, ambulance services (108 services) have formed the back bone of prehospital care in India. It is the fastest and first to reach service. However, traffic congestion acts as a major hindrance to reach the victim, especially in cities where the proportion of vehicular usage is on the rise. In 2014, of the total traffic accidents in India, maximum were reported during peak traffic hours; 15:00–18:00 h (16.9%) and 18:00–21:00 h (16.7%).[40] In India, the total number of registered motor vehicles has seen a drastic increase in the last two decades from 21.4 million in 1991–159.5 million in 2012.[41] In India, the lack of first aid care is proven to be one of the major problems in trauma care.[42] Poor road condition in the rural areas and lack of road connectivity to remote areas are the major hurdles in providing emergency care to the concerned areas.

Bike ambulance serves better than the traditional car ambulance through busy street, traffic jams, parks, and dense population in reaching the scene.[43] First responder (who are volunteer or health personnel, trained in BLS) decreases the unattended time for the victims. The bike ambulance service reduces the dispatch time significantly. Similarly, the availability of the first responder shortens the on-scene time. The first responder has been demonstrated to reduce the accident to care time and improve the survival rate.[44]

Description of bike ambulance services

The bike ambulance may be a motorized or nonmotorized vehicle. The nonmotorized bike ambulance was in the use in the early half of the last century and is now restricted to some parts of Africa. The cost of bike ambulance available in India varies from 1.5 lakh rupees to 2 lakh rupees. The bike ambulance is equipped with various emergency care medical items such as stethoscope, pulse oxymeter, bandages, and IV normal saline apart from basic drugs.[45] The bike ambulance's driver is generally a trained paramedic but can be a volunteer who has undergone training in first aid care and BLS with a driving license. The bike ambulances were driven by trained paramedics who were envisaged to reach the site within 10 min and provide basic first aid to the victim till the four-wheeler ambulance arrives.[46]

Evolution of bike ambulance services

The use of ambulance service dates back to World War-I with American version had stretchers and the French version had side car to carry and transport the victims.[47] The initial years of EMS in India, especially in the last century were urban-centric, fragmented and protocol driven, notably centralized ambulance and trauma services in Delhi, CMC Vellore and SRMC, Chennai.

The year 2005 brought a paradigm shift in EMS. Free universal access to prehospital care was developed on a public private partnership model in Andhra Pradesh using four-or three-digit helpline code like 108. As of now, India has got two public funded ambulance services “108 and 102” which are known by their helpline numbers. More recently, the NHAI has created the helpline number “1033” for emergency trauma care on highways.

The ambulances in early years of EMS in India were commonly described as dead body carrying vehicles as >95% of ambulance were without necessary equipment/oxygen or trained personnel to provide first aid care. Despite inclusion of necessary equipment and medicines in ambulances later, lack of trained human resources prevented India from implementing Western EMS model of Stay and Play. Rather Indian EMS adopted the “Scoop and Run” model to buy time for golden hour.

Under public-private partnership, the “First responder” bike ambulance (thirty in number) was recently launched in one of the capital cities in South India for RTI victims. A well-trained paramedic is the “first responder” and shall give first aid to the victim until help from other sources arrive.[46] Being a two-wheeler, the bike ambulance can reach the spot of necessity faster than a conventional four-wheeler ambulance. Thus, it not only utilizes the “golden hour” period to the maximum but also adds an extra “platinum 10 min.”[46] Following the footsteps of Karnataka, other states such as Gujarat, Maharashtra, and Himachal Pradesh have started the bike ambulance services as an initial step to provide care to the patients.[47] More recently, Early Trauma Management course has been offered by various hospital for the paramedical personnel as well as volunteers.[48]

Bike ambulance services in India-challenges and way forward

Despite modernization of trauma care services, a huge gap still exists in provision of pretrauma care services in India. Although efforts are being made to improve the pretrauma care services, it remains in the rudimentary stage. The development of fully functional effective prehospital trauma care services still remains a distant dream. The prehospital trauma care services in LMIC face constraint in providing adequate timely patient care and spatial coverage.[31] Lack of stringent traffic rules, inadequate logistics, and trained human resources further weaken the prehospital trauma care services.

Public funding for such comprehensive prehospital trauma care network is the major hurdle. India is still fighting against communicable diseases such as tuberculosis, malaria, and respiratory infections, and first priority is being given to maternal and child health problems. In this scenario, the special budgetary allocation for pretrauma care services remains a conundrum. Various private health-care providers have started such services but affordability for poor remains a major barrier.

Lack of trained workforce in prehospital trauma care poses a bottle neck to this service. The training and courses offered for prehospital trauma care are fragmented and not uniform. Majority of such courses are home-grown (institution/provider specific) and not standardized. There is a lack of any single central authority to regulate the curriculum of training and learning. A special course for “first responder” that caters to the demand of specialized skills need to be developed. Training should focus on judgment at critical points and timely planning of actions (”right thing” at the “right time”). A good proficiency in two-wheeler driving is a must. All of these go hand in hand to make the best of “first responder” bike ambulance service. The “first bike” responder ambulance service in India can definitely take on its own and spread its wings to cover various other different domains. Not only paramedical personnel but also volunteers can be trained as per the standardized module; this build-up of volunteer base may come in need at the time of disaster. This service can be used in rural and difficult to reach areas, than limiting itself to the accident victims in urban areas.

The onus is now on the government, the health system and all other allied public systems to improve upon the concept and ensure its sustainability. The National Ambulance Code developed in 2013 categorizes any “first responder” vehicle to “Category A” of road ambulance type.[49] However, a special guideline manual for the “first responder” bike with all engineering specifications should be developed and standardized for the future benefits. As of now, the bikes launched are gear bikes which are mostly driven by males, and hence, developing and standardizing a two-wheeler for females should also to be done.

Based on the prehospital trauma life support requirements, the equipment that needs to be carried in the bike ambulance should be regulated. The first responder bike should have an in-built Global Positioning System for tracing. Effective follow-up support system should be established such that once the first responder is set into action; the emergency team follows it up as early as possible. Lack of authentic data on trauma hinders the development need-based policy, and the lack of awareness is another challenge at the ground level.

India has got a vast network of hospitals and health institutions which can provide the much-needed information and services. The enriched network of self-help groups in villages, youth clubs in small towns, NGOs, and other social organizations at various localities can complement in this endeavor by providing community level information and services.

As the research and innovation in emergency prehospitalization care in India is still at its infancy, this new idea can be taken up at a nationwide level to improve “timely” first aid services in trauma care.


  Conclusion Top


Road traffic accidents and injuries are on rise in LMICs such as India. “Golden hour” period, which improves the survival probability of injured persons, is lapsed due to traffic congestion, topography, poor transport connectivity, and remoteness of scene when the traditional car ambulance is used. Bike ambulance and first responder seem a complementary vision in providing prehospital trauma care services negotiating the hurdles of car ambulance services. However, the public funding, appropriate guidelines, and skilled manpower form the bottleneck. The start of bike ambulance and first responder services has given a new direction to prehospital trauma care services in India. The onus of the sustainability of this endeavor lies with the government with co-operation from other stake holders to make it spreads its wings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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