Reproduced from: http://www.indialegallive.com/viewpoint/assistant-ambulance-officers-save-a-life-first-65657,
published May 19, 2019
The debate over Assistant Ambulance
Officers is needless, as in any medical emergency, what is vital is to save the
life of the patient, even by a bystander
By Dr KK Aggarwal
A scheme started by the
Delhi government in February seems to have run into trouble and has reached the
Delhi High Court. A PIL has said that Assistant Ambulance Officers (AAOs) who
are assigned the job of driving two-wheeler First Responder Vehicles should
also be trained paramedics. However, the Delhi government has said that they
will not transport patients and will only give basic medical assistance until
an ambulance arrives.
AAOs have been trained in
basic life-support techniques, have commercial driving licences and a work
experience of more than 20 years. However, in this scheme, there is not much
efficacy due to the limited knowledge and training of AAOs. They are not even
authorised (or qualified) to administer an injection.
To understand their job,
we need to first understand the laws. The government has powers to allow
healthcare workers to give treatment under Clause 23 of Schedule K of the Drugs
and Cosmetics Act.
As per the Clause, drugs
supplied by certain categories of workers are exempted from the provisions of
Chapter IV of the Act and the Rules which require them to be covered by a sale
licence, provided the drugs are supplied under the Health or Family Welfare
Programme of the central or state government. The workers are:
·
Multipurpose workers attached to primary health centres/sub-centres.
·
Community health volunteers under the Rural Health Scheme.
·
Nurses, auxiliary nurses, midwives and lady health visitors attached to urban
family welfare centres/primary health centres/sub-centres.
·
Anganwadi workers.
Similarly, malaria
workers are given anti-malaria drugs and do malaria testing, ASHA workers are
allowed to give Gentamicin injections to newborns and methergine for postpartum
haemorrhage, a leading cause of maternal mortality, before the patient is
transferred to a hospital.
There is also a provision
in the Medical Council of India ethics rules where a technician can be trained
by a doctor. It does not talk about institutional training. It says: “A
registered medical practitioner shall not issue certificates of efficiency in
modern medicine to an unqualified or non-medical person.” This does not
restrict the proper training and instruction of bona fide students, midwives,
dispensers, surgical attendants, skilled mechanical and technical assistants
and therapy assistants under the personal supervision of physicians.
Similarly, in cases of a
cardiac arrest, even bystanders are allowed to provide cardiopulmonary
resuscitation (CPR). There are three phases of cardiac resuscitation lasting a
total of 10 minutes. No doctor can reach in 10 minutes in an emergency and that
is why a first responder is important.
The first phase of
resuscitation is the electrical phase, lasting four to five minutes after
sudden cardiac arrest (SCA). Immediate direct current cardioversion is needed
to convert an abnormal heart rhythm to a normal heart rhythm. Performing chest
compressions while the defibrillator is readied also improves survival. Then,
there is the hemodynamic phase or circulatory phase which is from four to 10
minutes after SCA. Chest compressions should be started immediately and
continued until just before defibrillation is performed. Then there is the
metabolic phase defined as greater than 10 minutes of pulselessness. This is
primarily based upon post-resuscitative measures. In these phases, the
administration of CPR by a lay person is an important factor in determining
patient outcome if the cardiac arrest takes place outside a hospital. Survival
after cardiac arrest is greater among those who have bystander CPR as compared
to those who initially receive delayed CPR from a trained technician. In
addition to improved survival, early restoration in circulation is also seen.
There is also the golden
hour in medical practice when immediate care is required. Delay in treatment
even by a few minutes can take away a life. In emergency medicine, the golden
hour refers to the first hour following a traumatic injury during which time
there is the greatest likelihood that prompt medical treatment will prevent
death.
If bleeding can be
stopped and a person infused with enough fluids within the first hour, most
trauma deaths can be avoided. There is also the platinum 10 minutes which
refers to the first 10 minutes after trauma when first-aid can be started.
The importance of time in
medicine can be gauged from the following:
·
Door to ECG Time: This is an important terminology in the treatment of heart
attack. One should get an ECG within 10 minutes of chest pain. A prolonged
door-to-ECG time is associated with an increased risk in a heart attack.
·
Door-to-doctor time in paralysis: In an emergency department, the time from the
arrival of the patient to initial physician evaluation should be less than 10
minutes in strokes, otherwise the mortality will be high.
·
Door to antibiotic time in community acquired pneumonia is the time to start
antibiotics. Guidelines suggest that all patients hospitalised with community
acquired pneumonia should receive antibiotics within four hours of admission in
a hospital.
·
Door to antibiotic time in meningitis of more than six hours is linked to high
mortality.
·
Door to needle time in an acute heart attack is the time before which a
clot-dissolving drug should be given.
·
Door to balloon time is less than 90 minutes for angioplasty and stenting in
acute heart attack.
Even the Indian Penal
Code (Section 92) recognises the importance of an act done in good faith with
consent. It says: “Nothing is an offence by reason of any harm which it may
cause to a person for whose benefit it is done in good faith, even without that
person’s consent, if the circumstances are such that it is impossible for that
person to signify consent, or if that person is incapable of giving consent,
and has no guardian or other person in lawful charge of him from whom it is
possible to obtain consent in time for the thing to be done with benefit.”
In that sense, motorcycle
first responders are important. They are not doctors and will give life-saving
intervention only when required. Under Section 88, the same Act is not an
offence if done with consent. Calling an ambulance is an implied consent.
In this whole issue,
there is the question of paramedics. Are there enough paramedic courses,
colleges and councils? From the Red Cross, one can do a short course on
first-aid and qualify to be a paramedic. But is that enough?
The answer lies in
training and not the degree as far as first-aid is concerned. It is important
to manage the golden hour and hand over the patient to qualified doctors with
the arrival of a proper ambulance.
Time is of essence in
medical care and if basic first-aid is being given, why quibble about whether
the person has a paramedical degree or not?
Dr KK Aggarwal
Padma Shri
Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania
(CMAAO)
Group
Editor-in-Chief IJCP Publications
President Heart
Care Foundation of India
Past National President
IMA
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