By Dr. George Jacob

The Kerala government recently decided at a high-level meeting chaired by Chief Minister Pinarayi Vijayan to draw up a comprehensive trauma care program to ensure emergency medical assistance for Road Traffic Accident (RTA) victims.

There always has been a thorn in the flesh of the rosy picture that Kerala has been able to draw on the health front by achieving health indices comparable to the ‘developed’ world, including Scandinavian nations. These nations are considered to be the healthiest going by measurable health indices.

Therefore the recent statement by Uttar Pradesh Chief Minister Yogi Adityanath is considered by many as favorite to win the price for ‘the best joke to have come out of India in 2017’ till date. Yogi was not impressed by Kerala’s remarkable achievement and advised the state to look up to Uttar Pradesh for tips to improve its health standards.

That thorn in the flesh has been the dearth of emergency medical treatment available to victims of mounting RTAs in the southern state. This glaring paucity of emergency medical care for trauma victims during the crucial ‘golden hour’ has denied many a trauma victim timely and proper medical care. This has led to numerous avoidable deaths.

The case in point is that of Murugan, a migrant manual laborer from Tamil Nadu. Murugan, recently, was shunted from one hospital to another, including the premier Government Medical College Hospital in the state capital, Thiruvananthapuram on some pretext or the other. While being shunted from hospital to hospital, he died for want of proper and timely treatment. This left Kerala’s much heralded ‘health standards’ red-faced. This incident had the powers- that-be to sit up and take notice.

What is the concept of the ‘golden hour’? ‘Golden hour’ or ‘golden time’ in Emergency Medicine refers to a time period usually lasting for a hour or even less following trauma or medical emergencies like heart attack or stroke, during which prompt, targeted and focused medical treatment can prevent death. The thorn in the flesh of ‘healthy Kerala’ has been a glaring deficiency of prompt medical treatment during the golden hour in case of trauma victims, who often die on the state’s roads- deaths that could have been prevented were it for more focused and timely initiation of proper treatment.
The state government’s recent initiative aims to nip away that thorn in the flesh by:
• Meeting insurance companies to finalize a comprehensive trauma care policy that will include even private hospitals, who will make use of the Road Safety Fund to meet initial expenses when a trauma victim arrives at the Emergency Department of these hospitals.
• By ensuring availability of special ambulances with advanced facilities to ensure trauma victims reach healthcare facilities within the golden hour.
• Launching advanced trauma care facilities in government medical colleges, District and Taluk hospitals, and major private healthcare facilities.
• The government itself Meeting the initial expenses incurred by trauma victims within the first 48 hours, so that no one is denied the crucial initial assessment, resuscitation and treatment for ‘want of money’. This money disbursed by the government will be recovered from concerned insurance companies, which will have to be sorted out by extensive deliberations, which is sure to be an arduous and long-drawn out process. According to the government, ‘treatment should not be denied to any accident victim brought to hospitals. The practice of providing treatment based on the financial capacity of patents should end.’, and rightly so! After all, in the practice of medicine, especially in emergency, considerations like the ‘financial clout’ of the patient, and profit of treatment administered ought not to be considerations at all.
• Developing software to ensure availability of specialized ambulances and to choose nearest hospital.
• Setting up a centralized call center to manage all information alluded to above.
• Launching a rejuvenated trauma care facility using the Kerala Road Safety Fund and the Social Responsibility Fund of Kerala Road Transport Project along with budget allocations in this regard.
• Entrusting the responsibility to set the ball rolling in a time-bound manner to the secretaries of various departments including health, finance, transport and public works.

Is the state so bad with regard to traffic accidents that have had the government embark on an ambitious slew of measures such as this?

RTAs touched an all-time high during the last six years with 39,029 accidents being registered in 2015, while it was 36,282 in 2014.As many as 3,130 lost their lives in road accidents in 2016, compared to 4,049 in 2014. Causes of these accidents in Kerala form a spectrum which includes: ignorance of, or refusal to adopt sane driving habits, as per the book, increasing number of the so-called ‘new generation’ vehicles, especially two wheelers, on the roads which lack facilitates from them to ply on. Another glaring cause is aggressive driving by those driving heavy vehicles, exemplified by: over-speeding by private buses, competing with each other for passengers, tipper Lorries that carry sand illegally mined from riverbeds, and vehicles transporting locally and illicitly brewed liquor. Other causes are overtaking by two wheelers through the left side of unsuspecting larger vehicles, sleeping at the wheel, use of mobile phones and other gadgets while driving, reluctance to use helmets, and drunken driving.

What happens at the Emergency Departments of hospitals when a trauma victim arrives?
If the injuries are minor, and do not merit observation, the patient is discharged after providing first aid.
If the injury is major, that it merits observation, or specialized treatment procedures like surgery, they are admitted preferably in the ICU, or at least in specialized wards. When such a seriously injured patient arrives, he or she is put through a battery of investigations like various scans, blood investigations and other specialized investigations like the ECG, an Echocardiogram, to (1) to assess the extent of injuries, and (2) to assess the patient’s fitness to undergo major procedures like Surgery, angiography or other relevant procedures under anesthesia. It is at this juncture that hospitals solicit a sum of money, referred to as ‘advance’ to cover for expenses incurred for the above said investigations. This is a practice rampant in private hospitals. This seemingly unsavory and cruel practice, not in keeping with the nobility of medical profession, especially during emergencies is usually not taken lying down by the patient or the attendants. Nobody is expected to walk around with large amounts of money to pay the advance sought. It is here that the government has decided to step in, by having the advance and initial expenses paid either by the government itself, or by insurance companies. When a huge sum of money is solicited as advance to cover initial treatment expenses, two eventualities are possible (1) the patient and the attendants decide to get discharged at Request to seek treatment in relatively cheaper hospitals like those in the public sector, or, (2) refuse expensive investigations, leaving initial evaluation dangerously compromised. Patients admitted to ICUs, especially in private hospitals for evaluation and treatment procedures like surgery could also find the going beyond them and their families. Eventually, they seek discharge at Request to continue treatment at an affordable facility. If the government’s proposal to cover treatment expenses for the initial 48 hours materializes, such confusions and dangerous fallouts like discharging half-treated critically injured patients at request can be avoided.

What can be done to improve the grim situation existing in Kerala, with regard to RTAs and treating its victims?
• Improve conditions of the roads that are far from adequate to cater to traffic density bursting at its seams. Unscientifically constructed medians and dividers in highways must be dismantled.

Who can forget the fate that befell the capable and versatile cine actor of Mollywood- Jagathy Sreekumar? Roads, especially highways on which vehicles ply at high speeds must be adequately lit, well-signaged, and adequately marked with reflectors and bright, luminous paints. All potholes, invariably found across the length and breadth of the state at the receiving end of copious rain must be religiously filled. Bumps must be marked and forewarned well in advance. Pedestrians and cyclists must be provided adequate facilities on the roads they share with large vehicles plying at great momentum.
• Law enforcing agencies must ensure that every rule in the book is religiously observed by motorists. There is no dearth of law and rules meant to ensure safety on Indian roads. What is glaringly lacking is the resolve on the part of authorities concerned to implement them uncompromisingly and without favoritism. Drivers’ tendency to run amok on the roads must be dealt with firmly, with whatever it takes.
• On road 24-hour services of personnel trained in Advanced Trauma Life Support must be made available aplenty, at regular intervals, especially on major highways.
• Trauma care facilities in hospitals in the public sector must be spruced up, so that less expensive, yet state-of-the-art facilities are made available to the common man unable to avail of high-end and much superior, but expensive treatment available in private hospitals, especially those in the corporate sector, which have made dispensation of medical care a burgeoning business in the country and the state, denting the nobility and credibility of medical profession badly in the process. This has only contributed to the profession and the personnel involved earning suspicion, mistrust and even plain wrath bordering on violence of the common man, bringing a great deal of discredit to the profession and personnel involved.