emergency medicine and its future ... medicine and its future development in bangladesh by prof....

EMERGENCY MEDICINE AND ITS FUTURE DEVELOPMENT

IN BANGLADESH

BYPROF. MOHAMMAD OMAR FARUQ

MD, FACP, FACEP, FCPS(AMERICAN BOARD CERTIFIED IN INT. MEDICINE &

EMERGENCY MEDICINE)PROF. OF CRITICAL CARE MEDICINE,

BIRDEM.FEB 22, 2009

DO YOU RECOGNIZE THIS ROOM ?

DO YOU RECOGNIZE THIS WARD?

What you see are the two extremes of thespectrum of emergency care in Bangladesh

MEDICAL BASIS FOR EMERGENCY MEDICAL SERVICES

1. Emergency Cardiac Care2. Trauma Care3. Adult Medical Care4. Pediatric Care5. Rural EMS

PHILOSOPHY OF EMERGENCY CARE

Does it work in Bangladesh ?

A successful EMS system ensures that all individualshave access to emergency care regardless of theirability to pay or type of insurance coverage

An important principle of EMS is that all individualsdeserve timely access to the system when necessary

EMS (EMERGENCY MEDICAL SERVICE)

Constitutes the extension of emergencymedical care into the community involving thehospital and its emergency department

LOCAL ROLE IN EMERGENCY MEDICAL SERVICES

1. Personnel2. Training3. Communication4. Transportation5. Facilities6. Critical Care units7. Public safety agencies8. Access to care9. Transfer of care10. Public information and education11. Disaster linkage


Personnel:

EMT Citizen volunteers etc.


Training:

FR (First Responder) eg. Police, Firefighters

EMT (Emergency Medical Technicians)

EMT.B (Emergency Medical Technician Basic)

EMT.I (Emergency Medical Technician Intermediate)

EMT.P (Emergency Medical Technician Paramedic)


Communication:

911 in USA, Canada 000 in Australia 999 in U.K. 112 in E.U.

What about Bangladesh ?


Transportation:

Ground Ambulances BLS Ambulances ALS Ambulances Air Transport


Facilities:

Closest appropriate hospital Designated trauma centers


Critical Care Units:

Tertiary care facilities for: Trauma Neonatal Intensive Care High Risk Obstetrics Burns Neurosurgical and Cardiac Care


Public Safety Agencies:

Police Department Fire Department


Access to Care:

Regardless of ability to pay Timely access


Transfer of Care:

From one facility to another facility


Public Information and Education:

How to use the system


Disaster Linkage:

Integral part of disaster preparedness Involves in planning and practice drills

EMERGENCY ROOM IN BANGLADESH

Typical Emergency Room in a Western Country

FACTS ABOUT BANGLADESH

Emergency Facilities are urban centered Semi-urban facilities are less adequate Rural facility absent


Our only hope in a large city is the Medical CollegeHospital Emergency Room

TYPICAL SCENERIO IN A MEDICAL COLLEGE HOSPITAL ER

EMO triages the patient and hurriedly admits thepatient into different services after filling out theadmission form

First aid/minor laceration attended upon During day patient may be referred to O.P.D. Arrested patients are usually pronounced dead or

sent to inpatient for resuscitation


The luckiest patient is someone who is seen by thedepartmental professor or consultant, who happensto be there at the right time


There is nothing called “NO VACANCY” All admissible patients will be admitted If the ward is full they will be kept lying on cement

floors of wards, corridors or even the lobby areas


In the worst situation, patients’ family may be told totake patient elsewhere as patient care facility is notavailable

SCENERIO IN A PRIVATE CLINIC/ HOSPITAL

Patient is either admitted directly or told to go toanother facility/specialty Government facility

If he is poor, told to go to MEDICAL (Medical CollegeHospital).

FACT FINDING:DHAKA MEDICAL COLLEGE HOSPITAL

1200-1500 BED INPATIENTER:

Daily census:600-700 Yearly census:219000-255500 In-charge: Trauma RS On duty EMO:2-3 per shift No CPR facility No cardiac monitoring or ECG No other lab facility Nebulisation facility for asthmatic Gastric lavage for poisoning Hospital has ICU/CCU.

OBSERVATION ROOM

FACT FINDING:IBN SINA HOSPITAL180 BED INPATIENT

ER: Daily census:30 Yearly census:11000 No on duty doctor, on call doctor available In-charge: S.M.O on duty CPR done with help of ICU doctors Defibrillator available Hospital has ICU

FACT FINDING:BIRDEM HOSPITAL

500 BED INPATIENTER:

Daily census:150(includes walk in D.M patients) Yearly census:48000 On duty EMO:2 per shift In-charge: RP CPR done with the help of ICU doctors Defibrillator out of order Nebulisation facility available Hospital has ICU/CCU

FACT FINDING:SQUARE HOSPITAL

280 BED INPATIENTER:

Daily census:40 Yearly census:15000 In-charge: Consultant Pediatrics surgery On duty EMO:2-3 per shift CPR (ACLS) done in ICU Cardiac monitor in all beds, portable X-ray available Mini O.T Observation room Mechanical ventilator Most staff CPR trained Hospital has ICU/CCU

SQUARE HOSPITAL

Floor space of DMCH ER and Square ER are almostsame

However, DMCH handles 700 patients per day, whereas Square handles only 40 patients a day

Please compare resource and service allocation perER patient between the two

Please comment on the disparity

IS AN EMERGENCY ROOM A

Glorified Walk in Clinic orA Triage Center orA First Aid Station ?

WHAT IS NEEDED IN AN IDEAL E.R OPERATION

Prompt triaging. Trained manpower : Credential of doctors & nurses

Space, equipment, supplies Backup consultation services Critical care facilities: ICU, CCU CME Organized EMS system

TRAUMA CARE IN BANGLADESH

Our country is famous for road traffic accidents

TRAUMA CARE IN BANGLADESH

We need Trauma centers:

Level I Level II Level III Level IV

LEVEL I: TRAUMA CENTER

Provides the highest level of surgical care to traumapatients

It has a full range of equipments 24 hours a day Has an education program, preventive and research

program

LEVEL I: TRAUMA CENTER

24 hour in house coverage by general surgery and prompt availability of care in varying specialties like:

Orthopedic surgery Neurosurgery Plastic surgery Anesthesiology Emergency medicine Radiology Internal medicine Oral & maxillofacial Vascular surgery

Level I & II do not exist in Bangladesh

DMCH is the only officially recognized trauma unit inthe whole country

It has a separate burn unit It can be labeled at somewhere between level III &

level IV

NITOR (Pongu Hospital) claims to be a traumacenter, but it is not so

TRAUMA WARD OF DMCH

Our best bet is in developing primary, secondary &tertiary care hospitals within the Government healthcare system, using the medical college hospitals astertiary care hospitals and as level III Trauma center

To develop DMCH, CMCH, RMCH, SMCH as theregional level I & II trauma centers

REGIONAL TRAUMA CENTERSIN BANGLADESH (proposed)

Do you know that department of Roads & Highways(Ministry of Communication) oversees planning fortrauma care in Bangladesh?

Proposal for establishment of an Acute Trauma Care Center in Bangladesh

DISASTER MANAGEMENT

Disaster Management is the discipline that involvespreparing for disaster before it occurs & disasterresponse when it occurs.

DISASTER MANAGEMENT IN BANGLADESH

Role of EMS system

4Rs OF DISASTER MANAGEMENT

Reduction = Mitigation Readiness = Preparedness Response Recovery

IN COLLABORATION WITH

EMERGENCY CARE IN RURAL BANGLADESH AND DISASTER PREPAREDNESS

EMERGENCY CARE IN RURAL BANGLADESH

CALENDER FOR DOCTORS AT THANA LEVEL

In case of snake bitenever waste your timegoing to traditionalhealer

Send the patientimmediately to nearesthealth facilities whereanti-venom is available

EMERGENCY MANAGEMENT IN BANGLADESH: REALITIES

Concept of modern day emergency care is unknown to our medical graduates

Pre-hospital EMS system exists in a very primitive form where ambulances are nothing but patient carriers

Most ERs with exception of 2-3 large private hospitals function as glorified triage stations or walk in clinics

EMOs are merely “Traffic Police” directing patient disposition EMOs are the most under recognized, poorly trained & future-less group of young physicians

EMERGENCY MANAGEMENT IN BANGLADESH: REALITIES

CPR not available in 99% of ER Emergency medicine as a specialty is virtually

unknown among our senior colleagues The burden of emergency care has fallen on inpatient

units, ICU, CCU

We need Govt. patronage to establishemergency care delivery in Bangladesh

Why ?


Private hospitals are least interested in developingE.R rather than in establishing ICU/ CCU becauseICU/CCU are profitable


Emergency is the most important department in ahospital in terms of service to the community but it isthe most expensive and least profitable in terms ofmanagement


Who will pay for the cost of emergency care ?

We cannot afford to have a nationalized health services like those of Canada or Sweden

FEW RECOMMENDATIONS

A. Update medical colleges & nursing curriculum: Emergency medicine, Critical Care , CPR, all should be stressed appropriately

B. Develop EMS Training AcademyC. Government recognition of emergency medicine as

a specialty: Eventually postgraduate courses should be developed in our medical colleges

D. Public education using mass media: BLS, First Aid, Trauma prevention & disaster preparedness

E. Trauma center: Regional & local.

We also recommend that disaster planning &preparedness, EMS, emergency facilities should becoordinated by a separate directorate now underDepartment of Health, Government of Bangladesh

EPR (Emergency preparedness & response) programshould be upgraded

Story of an Unfortunate Son of Soil: Victim of Trauma

Story of a Fortunate Cardiac Arrest Victim

We want emergency care for everyone as ourbirth right - any kind, any time, any where -not as an exception and not as a favor ofluck blessed from the sky

We do not want to see the repetition of thescenario of the unlucky leader of our nation

FOR BANGLADESH WE ARE HOPEFUL. THERE ARE WAYS TO SURVIVE

EMERGENCIES

THANK YOU

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