Paramedic training in India: The Fortis Emergency Medical Service Program
Dr Alok Srivastava
Head – IERS, Training and Academics & Research
In conjunction with the Delhi Commonwealth Games in 2010, Fortis Healthcare made the decision to train and deploy dedicated ambulance professionals as staff on its ambulances. These EMTs were intended to provide the highest quality of emergency care for patients as they are being transported to the hospital (or between hospitals). In addition, these medics could provide competent support and assistance to the physicians aboard the ambulances for critical patients.
To facilitate this goal and ensure the highest quality of trained professionals, the project was undertaken in partnership with experts from the University of Utah, a well-respected medical university located in Salt Lake City, Utah, in the Western United States. The Division of Emergency Medicine of the University of Utah has established expertise in the training of EMTs and paramedics and was therefore chosen to expedite this project. The plan was to utilize a structured training curriculum that mirrors the well-established U.S. system, but to modify it to the needs of Fortis and to the Indian laws and culture. After the successful execution of the EMT program, a second curriculum to train highly advanced Paramedics, capable of independently managing critical patients in the ambulance, was developed. The first class of paramedic students is now in training. Future plans include development and initiation of a full Emergency Medicine residency program for physicians. All of these emergency care programs reflect the emphasis Fortis places on providing the highest quality, state of the art medical care for its patients.
The Fortis Ambulance Program
During the development of the Fortis Ambulance Program EMT and paramedic training curricula the consultants from the University of Utah visited Fortis for several meetings to determine the exact requirements of the program and to tailor the standardized U.S. training curriculum to these needs as well as to the differences in Indian medical and social standards. The result was a training curriculum customized to Fortis requirements, but substantially the same as the strict U.S. requirements. This innovative curriculum is designed to train EMTs and paramedics to handle both the routine and the critically ill patients during the process of their transportation from home to the hospital.
The first batch of EMTs completed their training in 2009 and subsequent classes were launched using a “train the trainer” model, whereby the most accomplished students from each class were given special instructor training and were then utilized to teach subsequent classes. By this method, the Fortis training program achieved self-sufficiency and cost-effectiveness, such that the consultants from Utah were no longer required after the first several classes were completed. A total of 186 EMTs were trained using this curriculum and these EMTs were deployed to ambulance operations throughout the Fortis system.
In late 2011, the consultants from the University of Utah finalized the Fortis paramedic training curriculum and the recruitment of the first class of paramedic students was completed. To ensure quality, the recruitment requirements were severe: students had to have completed nursing school, have basic English proficiency, and pass a rigorous screening examination. They began the 1200 hour training program in early 2012 and are scheduled to sit for their final examinations in January 2013. Their training has been a full-time schedule of classroom didactics, hands on technical skills development, and clinical postings at several hospitals, including emergency department, heart command, intensive care unit, pediatrics, and ambulance service at Fortis Escorts hospital, along with trauma unit and Ob/Gyn postings which are scheduled at Holy Family Hospital.
These programs have been organized and taught by Dr. Alok Srivastava, Director of Ambulance Operations for Fortis Healthcare. The consultants from the University of Utah, Peter Taillac, MD and Chris Stratford, RN, have provided regular curriculum updates, PowerPoint presentations, examinations and program supervision. This has included visits at scheduled points in the training program to perform knowledge and skills testing and remedial training on areas found to be weak, in order to ensure full capability and competence by this first class of paramedics. After graduation in January, the medics will be assigned duties on the ambulance based out of Escorts and will perform patient transportation duties across the NCR. Several of the top-performing graduates will also be assigned teaching duties for the next class of paramedic students to begin immediately in February 2013.
The eventual goal of the program is to outfit every ambulance in the Fortis system with EMTs and paramedics trained under this strict and exacting program, extending Fortis’ reputation for clinical excellence out from the hospital and into the streets. These highly trained paramedics will assist in the full integration of the ambulance program into the overall Fortis healthcare system, with direct radio contact with physicians and specialists at the receiving hospital, allowing seamless transitions of care between the ambulance and the emergency department. Future plans include beginning formal Emergency Medicine Residency training for Fortis physicians, modeled after the very successful American Board of Emergency Medicine three-year curriculum.
The care of the patient begins with the call for help. These EMT and paramedic training programs, combined with Emergency Medicine specialty training for physicians, will ensure that Fortis patients receive the best emergency care available in India from the moment the Fortis ambulance personnel arrive at their side and carried through their entire hospital experience. These innovative training programs will further advance Fortis’ position as a recognized leader in cutting-edge emergency care.
What is EMS?
Emergency Medical Services, or “EMS”, is a concept well developed in the United States and Europe, but relatively new in India. It is based on the concept that life-saving care administered very early in the patient’s care, during the “Golden Hour”, can result in improved outcomes, decreased morbidity and mortality, and a better quality of life for patients. Trained EMTs and paramedics arriving at the scene of an accident, or at a critically ill patient’s home, can provide an immediate assessment of life threats and initiate care to stabilize the patient prior to and during transportation to the hospital emergency department. Time-critical conditions such as stroke, ST-elevation MI, and serious trauma clearly benefit from immediate recognition and treatment. In addition, less-critical patients can be made more comfortable during the transport, by the provision of oxygen, IV fluids, and pain medications by the trained paramedics. This ability for paramedics to care for the advanced medical needs of patients both improves the quality of care for the patient and also lessens the need to have a physician accompany the patient during transport to the hospital.
The U.S. and Europe have similar EMS systems, with simple public access by a universal phone number, centralized dispatch, and rapid response by both public and private emergency providers. However, most European systems, with the exception of Great Britain, utilize physicians on ambulances for critically ill patients, resulting in more treatment at the scene prior to transport. In contrast, in the U.S., Great Britain, and Australia, physicians rarely attend patients on ambulances. Instead, highly trained paramedics assess the patient for critical needs, provide stabilization care, and initiate rapid transport to the hospital emergency department. The emphasis is more on stabilization and rapid transport, with physician-level treatment provided at the hospital.
In the U.S., there are currently three levels of Emergency Medical Technician (EMT): EMT, Advanced EMT, and Paramedic. Their levels of training differ substantially. The EMT undergoes approximately 120 hours of training prior to certification. The Advanced EMT requires approximately 350 hours of training. The highest level of training, Paramedic, requires 1200 hours of training. This includes instruction, both didactic and clinical, in all aspects of emergency stabilization care, including trauma, cardiac, pediatrics, Ob-Gyn, neurologic, orthopedic conditions, and more. They are certified in Advanced Cardiac Life Support, Prehospital Trauma Life Support, and Pediatric Advanced Life Support.
EMTs at all levels operate under medical direction by a physician with emergency care experience. This Medical Director is responsible for all aspects of the medical care and training of the medics, including training on the medications and equipment utilized as part of their care. The Medical Director is also responsible to develop and approve the medical treatment protocols utilized by the EMTs. Medical direction is of two types: “off line” and “on-line.” Off-line medical direction includes the predetermined protocols and standing orders followed by the medics in the care of their patients. In addition, on-line medical control is provided by radio or phone contact with medical control physicians at base station hospitals. This “real time” medical control allows the medics to interact with the physician when needed to handle more complex or difficult situations.