Where do we stand in emergency care

Abdus Salam Khan, MD FACP
September,2012
 

 Welcome to the third article of the series of articles on emergency care. We will be discussing the level of infrastructure and the care in Pakistan. This will be another piece of the puzzle regarding the emergency care in Pakistan.

The first step in the direction of improving the emergency care is the realization about the present scenario, or the actual situation at ground. This evaluation although is critical, but have to be done in a non-judgmental way, so the focus of discussion should not get moved to fruitless discussion about the culprits.

MODES OF PROVIDING CARE:

Emergency situation comes without warning and it can happen at any time or any place. Usually people try to get help by themselves in the best possible way. As some of the situations may turn out to be of medicolegal values, certain emergency centers has to be bypassed to reach a place which can provide the needed help. Cost is another factor that plays a role in deciding where patients will end up for the care. Taking all these things into consideration, we formulated following list to group all the places that provide emergency care.

1-      Local General Practitioner’s Clinic. Although it is a very limited resource in scope, but it is the first place for majority of patients to get help in emergency situations. They provide care for a lot of minor emergencies, and if they cannot handle the situation they refer people to bigger centers.

2-      NGO’s run clinics. Their scope is even more limited, as compared to the GP’s. That may be because they have a specific mandate and limited expertise to deal with emergencies.

3-      Government dispensaries and small hospitals. These small level and peripheral hospitals were designed to extend the healthcare to the rural and peripheral urban areas. These centers do not play their expected role due to known reasons.

4-      Privately run small scale hospitals. These places are abundant in bigger cities and also plenty in rural and smaller cities. They have very limited emergency capabilities. They deal with most of the minor emergencies and some of the moderately complex problems.

5-      Privately run bigger institutions. These centers are mostly in the big cities and provide care for all sorts of emergencies except for medicolegal cases. They are better equipped but because of expense are out of the reach for the majority population.

6-      Armed forces system of Hospitals. Usually cater to the armed forces, but also to civilian population. It has decent system of emergency care, and can cater to almost all cases.

7-      Government run bigger Institutions. These were once the backbone of the emergency care in Pakistan, until private Institutions started sharing some of the burden and replacing them due to better facilities. These institutions take care of all emergencies including medicolegal cases.

LEVEL OF CARE.

In cases of emergency the care needs to be started at the place of emergency. This is done through pre-hospital care. This is an important part of the healthcare delivery, and in certain instances has a bigger role than hospital care.

  1. Pre-hospital Care. It is still a dream in Pakistan. Pre-hospital care is dependent upon a quick response with expert hands at the scene and a quick transport mechanism to the hospital in the best possible way with safety of the patient as the prime target. The infrastructure is grossly lacking and is insufficient.
  2. Hospital Care. We have a spectrum of places from rudimentary peripheral hospitals with no equipments to very decently equipped emergency departments. Smaller privately owned hospitals have smaller and less equipped emergency rooms, to level there dealing of minor emergencies. When problems turn out to be complex they refer patients to tertiary care places which are mostly Government run Institutions, and a smaller proportion end up in privately run institutions due to the cost constraints.

WHO PROVIDES THE CARE.

  1. Pre-hospital care. We can clearly demark the pre-hospital care into pre 1122 and post 1122 era. Pre-hospital care was non-existent and our ambulance system was merely a transport mechanism to deliver patients from one location to other. In 2004 1122 system was started  in Lahore and later on in 2008 Aman Foundation started an ACLS ambulance system and so elevated the level of pre-hospital care in Pakistan. Far from providing the care to entire population, at least it is a step in right direction and bring Pakistan a much needed expertise. These systems are operated by people with the right knowledge and right equipment to deal with emergencies out side the hospital.
  2. Hospital care. Like our pre-hospital care , our hospital is also in disarray. A casualty Medical officer usually does the triage and summon oncall specialists and sub-specialists to care for the patients. These CMO’s or casualty medical officers usually have no training and learn on job, and mostly depend upon the oncall team to deal with patients. They also provide minor care to the patients and usually are over-whelmed by the high volume of the emergency departments of Government Institutes. In smaller hospitals the CMO is the only person available and so the whole care depends upon the expertise of this medical officer. All complex cases are referred to bigger hospitals. These emergency physicians have no training of emergency medicine and usually work in the emergency as part time.

EXPERTISE OF EMERGENCY ROOM STAFF.

As discussed earlier the people that run the emergency departments have no training in emergency medicine. The similar scenario is also seen in the level of expertise of the paramedics and nurses who run the emergency departments. There is a complete lack of insight at the national level regarding the emergency care. A few private Institutions have started taking emergency care more seriously and they utilize trained staff for the emergency care. Otherwise throughout the emergency rooms in Pakistan untrained staff deals with patients, and heavily rely on timely help from oncall specialties and sun-specialties. This sometimes results in unnecessary delay and unfavorable outcome which is the major reason for the outrage of patients and family that we see at the emergency departments.

SUMMARY

In essence we can see clearly that we are running our healthcare system with no proper pre-hospital or hospital care of any world standard. The good news is that our pre-hospital care has become better in part few years and is a nice step in right direction. Our hospital based emergency care has to step up and increase the capability to match our patients demand. This is a combined effort and require effort from all segments of the population.

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This document is very important as it deals with the documentation of the the actual scenario in present day and time. Our emphasis is to bring about a positive change to the emergency care delivery so the delay is negligible and the care delivered is swift, appropriate and starts well before the hospital.

I await your comments. You can reach me at fastcare.doc@gmail.com

 

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