Above: Doctors supervising cardiopulmonary resuscitation training in New Delhi/Photo: UNI
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?
—The writer is President, Heart Care Foundation of India, and President-elect, Confederation of Medical Associations of Asia and Oceania