EMERGENCY - 24 HOURS

Providing an adequate response to any medical emergency round the clock is a formidable task. It involves having a well trained team, being able to mobilise it, and respond quickly and appropriately every time.

We are in a mountainous area, prone to accidents, landslides and varied presentations of trauma. Vehicles tumbling down steep ravines, floods washing bridges away and buses overturning are annual affairs. Though assaults and gunshot injuries are rare, there are enough people getting involved in fights to provide patient material to our emergency room. Besides trauma, there has been a rising incidence of heart attacks, and strokes among the local populace. Organophosphorus poisoning is commonplace, with comatose people arriving having consumed it with a suicidal intent.

In many mission hospitals, there used to be a system of a call book. There was a book in the emergency room. This book used to be filled by the nurse on call, and handed over to the security guard, who would proceed to tramp through snow in winter or saunter to the doctors house in good weather. Usually the doctors quarters would be located within the campus, at a variable distance from the emergency room.  Such a call system is totally inadequate in its response time to relevantly provide timely help in the narrow window period that is available to save a life. Sometimes the security guard may even decide to refresh himself with a smoke under a tree prior to delivering the call.

Telephones replaced that system, with landlines interconnecting the campus. Today mobile phones have come into vogue and even replaced the earlier system of black pagers hooked to the belt which made doctors feel very important. However, even this system is awkward and expends precious minutes waiting for the doctor to arrive, which can mean lives lost.

When we first arrived in Manali, resuscitation was more of a last rite than a genuine attempt at saving life.  Precious minutes were lost in waiting for the doctor to arrive prior to the initiation of resuscitation. We initiated a hands on course in resuscitation for all the nurses in cpr, which did make a difference. A further obstacle was being able to have the resuscitation equipment handy. Older wards often have narrow stairs which are formidable obstacles to the emergent transport of life saving equipment. We filled a plastic toolbox, the kind that is available in any department store with emergency drugs and equipment and provided them at every station. These can be grabbed on the go and made the initial response of the nursing staff much more effective.

At code sites, having enough hands available is an essential component to resuscitation. Tertiary institutions have a “code blue” protocol, where a code pager buzzes madly summoning a multitalented team to the bedside of the patient in minutes. Other institutions have had a system of overhead announcements or lights flashing indicating the emergency.  We provided a siren in different wards, with different tones indicating the location. The siren can be heard all over the campus, and proved very effective in summoning those within earshot to the location of the emergency.

Over time, with each of these developments, we have been able to revive patients who present to the emergency room pulseless or not breathing adequately for whatever reason.  In fact, when when a pulseless patient was revived, one of the nurses eyes suddenly lit us as she realized that “This actually works!”

Mobilising the operating theatre within minutes is also a formidable task. Having the scrub team and the anesthesia person within a few minutes of beckoning means stationing them within the campus. Because Manali is a small place, we have been able to move massive trauma to the operating table within ten minutes, which is an adequate response by any standard. This too has resulted in precious minutes and lives saved.

Though BLS and ACLS and ATLS today are buzzwords with a large amount of documented data on implementation and protocolisation, this does mean different things to different people at varied locations. Each area will have to modify and tweak the practical outworking of the resuscitative attempts. The bottom line being, it has to be efficient, immediate and effective, all the time, every time.