iej june_issue_2013_19_july_2013 - GVK EMRI

ISSN: 0976-1470Volume VIII, Issue IJune 2013Transforming Emergency Management

CEO MESSAGEMessage from Chief Patron & CEO, GVK EMRI 01Subodh SatyawadiChief PatronMr. Subodh SatyawadiChief EditorDr. GV Ramana RaoEditorial AssistantRajini. DanthalaEditorial BoardDr. Debashis AcharyaDr. Manisha BobadeDr. Manu TandonDr. MNV PrasadDr. Narmada Devi HadigalDr. Raghav DuttDr. Raja Narsing RaoDr. Rama PadmaDr. Sanjay MohantyDr. Shailendra SinghDr. Sridhar . DDr. Srinivasarao JDr. V.S.V. PrasadDr. Vivek SinghEDITORIAL ARTICLEEMTs and Essentials in Multi‐Casualty Incidents 03G.V. Ramana RaoORIGINAL RESEARCH ARTICLESApplication of NSSK Training Skills (Basic Resuscitation) At the Workplace by 10Health Personnel In Andhra PradeshP. Satya Sekhar, V. Jayasankaraiah and K. Pitchi ReddyAbility of A Trainee EMT To Learn How To Use Video Laryngoscope 21And Accomplish The Task of IntubationSrinivasa Rao J; Raja Narsing Rao HV; Ramana Rao GVComparing The Usage of Double Endopharyngeal Tubes Versus 30The Usage of Traditional Nasopharyngeal Tubes In Manikins WithUpper Airway Obstruction in Simulated Seizures in Pediatric Patients.Kumara Nibhanipudi, Roger Chirurgi, Brett Sweeney, Akash PandeyCASE STUDYEmergency Condition in a Neonate with Rare Congenital Anomaly, Tamil nadu 37Sailaja. P, Vimal. M, Jebin. TREVIEW ARTICLESNational Ambulance Code Constructional & Functional Requirements 41for Road Ambulances April 2013 (Extract)G.V. Ramana Rao

CEO MESSAGEGrowth of EMS in India – Crescendo PhaseExpansion of emergency responseservices in India has reached a crescendoin the recent past. Our recent experienceof launching of services in Uttar Pradesh,largest State in India with nearly 200million population, with 988 ambulancesin less than six months timeframe, was aphenomenal learning experience in theannals of EMS history world over. Ourprocess, people and performancecentered approach though tested andstretched, was able to prove itsrobustness at the end of the day in thisendeavor. For the EMS professionals,public representatives, public servants,policy makers such accomplishments arereal moments of pride. As an organizationGVK EMRI is keen that every person inthe country gets security and surety of aneffective emergency response service atthe earliest. GVK EMRI has once againbeen selected to operate 108 service inRajasthan, making us more responsible tomeet with the growing expectations ofpeople and Government. We now cover apopulation of more than 700 million in 15states and union territories. Many moreS t a t e s a r e i n v a r i o u s s t a g e s o fimplementation of 108 service. Theseevents of EMS expansion should beperceived by clinical leaders andacademic institutes of repute as anopportunity to measure changes –beforeand after, both in terms of healthoutcomes and impact by using direct andindirect indicators. Research studiesshould be proposed to measurebeneficial effects of such large scaleinitiatives to identify enabling factors andrecommend areas of strengthening forfuture expansions and long termdevelopment of EMS.In addition, to the EMS services in newregions, most states are offeringspecialized out‐of‐hospital services likeInter‐facility Transfers, drop‐backservices etc. GVK EMRI is selected toprovide I F T and Mahtari servicesIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 01

espectively by Governments of Assamand Chhattisgarh under NRHM. Thesenew initiatives by Governments arestrengthening the critical aspects out‐ofhospitalcare and referral systems at avery fast pace. These developmentsshould also draw the attention ofacademicians and researchers to conductquantitative and qualitative researchstudies.I am proud to inform that GVK EMRI hastill date responded to over 20 millionemergencies and saved nearly seven lakhlives. Our organization is at presenthaving a fleet strength of over 5300ambulances and employee strength of24,000.This issue of IEJ has interesting articles onuse of life support interventions andmanikin based training and a rare clinicalcase presentation as original researcharticles and review and editorial articleson national ambulance code and role ofEMTs in MCI. I am sure all these will addvalue to the science and practice of EMS.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 02

EMTs and Essentials in Multi‐Casualty IncidentsDr. G.V. Ramana RaoEMS systems must be fully geared up torespond to individual emergencies.Preparedness includes responding tocalls through a toll‐free emergencynumber in a timely manner at theresponse center; delivering qualifiedproviders to the scene; providingemergency care from basic to advancedpre‐hospital care, transporting ill orinjured to the most appropriate nearesthospital in well equipped ambulance.Reliable network enabling closed loopcommunication between distress callers,emergency response center staff, EMT inambulance, doctor in case of need for onlinemedical direction, pre‐arrivalinformation to the receiving hospital arealso equally essential. True value of EMSsystem will be revealed in ability tohandle more extreme circumstances as inthe case of Multiple Casualty Incident(MCI) and Disasters. All MCIs may beclassified as a disaster, but not alldisasters are MCIs. EMS is expected tobe stand‐by in all disasters. In simpleterms, MCI is defined as more patientsthan EMTs.Multiple patients may be very stressfulfor the responding Emergency MedicalTechnician. It is often confusing andchaotic. Management of initial minuteswill have implications on the totaloutcomes. EMS personnel should actsafely and effectively. Identification ofhazardous material avoids potentialexposure and injury to EMTs. Beforeapproaching the scene, EMT shouldkeenly observe the event from a distance.The purpose is to categorize whether theAddress for Correspondence:Dr. G.V. Ramana RaoChief Editor, Indian Emergency Journal & Executive Partner & Head,GVK Emergency Management & Research Institute, Hyderabad. Email: ramanarao_gv@emri.inIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 03

event is complete or ongoing. EMT needsto presume the cause of the event. EMSpersonnel should balance their personalsafety against the urgency of thesituation. The “LACES” principle forresponding EMS units should be applied:Lookout : Safety officer viewsoverall scene from asafe distanceAwareness : All must maintainsituational awarenessCommunications : Primary and secondarycommunications areneededEscapes : All must have apreplanned escaperoute from the sceneSafety Zones : An upwind and uphilldistant safe zone mustbe set up.Initial scene survey is important than thegreatest temptation and basic instinct of amedical person upon seeing casualties. Itwill be duty to direct EMS units as theyarrive at the area. Upon arrival of seniorpersonnel, fast but structured handovershould be performed.Immediately inform the EmergencyResponse Center (ERC). At least tworedundant communication technologiesmust be in place, based on resources andregularly tested. During the initialcommunication to ERC it is suggested touse acronym of “HELP ALERT”: Hazardous conditions, if any (chemicalfumes with wind direction to east), Event nature (railroad accident/ fall ofa bus in valley/ fire in a chemicalfactory), Location, Personnel and resources need basedon number of victims Alert HospitalsEMTs must remember that tasks thatneed to be accomplished for manypatients are the same as tasks thatremain to be completed for one patient,duty to provide emergency medical careto sick and injured patients. Where thereare only minor injuries, it may only benecessary to establish triage andtreatment center. In case, adequatenumbers of ambulances are quicklyavailable, it may not be necessary toestablish treatment area. Basic premisefor EMT in MCI is “if you do not control thesituation, the situation will control you”.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 04

If it is a major incident, many otherproblems need to address beyond justproviding patient care. Law enforcementauthorities need to become involved. Firesuppression and hazard mitigation is theresponsibility of the fire service. Best wayto deal with the complexity of the scenesis to develop management approach thatis flexible. Approach should also beexpandable. Large scale events requireorganization and administration involvingall emergency response service providers(police, fire and EMS staff). Large scaleevents also require calculated responseto the typical challenges faced includingcritical tasks of command, control andcommunication. These actions areimplemented by activation of incidentmanagement system. Coordinating withother arriving agencies, in particularPolice and Fire personnel, is pivotal.E M S must function within a predeterminedcommand and controlsystem. In other words, Casualtynumbers, type, severity, geographicdistribution as well as hospital distances,road conditions, and thus expected traveltimes dictate response magnitude.EMS providers who arrive first at scenebecome the triage officer. During scenesizeup additional help should berequested. Care is not provided duringtriage. Exception to interruption of triageis correction of immediate life threats(airway opening/ control of major activebleeding). For initial assessment EMTshould not spend more than one minuteto determine the priority of the patient.Level of consciousness, respiratorysystem and circulatory system are quicklyevaluated. Injured rescuers will not fallinto the triage system. Greatest good isexpected to be done to the greatestnumber of patients in MCIs. Patients areprioritized into four categories.o Priority‐0 (Black tagged, dead),o Priority‐1 (Red tagged, criticalunstable),o Priority – 2 (Yellow tagged, serious,potentially unstable) ando Priority‐3 (Green tagged, stableconditions, minor injuries, walkingwounded).“Red tagged or Immediate Treatment" isthe highest level of triage, and is assignedto those with major life‐threateninginjuries who are salvageable. Pa entsIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 05

with uncontrollable bleeding are taggedred. Green Tagged" is the second‐lowestlevel of triage, and is assigned to thosewith minor injuries who can get out of theincident area and to a treatment areaunder their own power. Announcementcan also be made in the public addresssystem that “if you can walk, please standup and go over to the secondaryassessment area (on your le / right).Pa ents with minor illnesses/injuries maybe transported by unconven onal meansor mass transit such as local buses. Theaccuracy of field triage can be thought ofas the degree of match between theseverity of injury and level of care. Duringthe triage opera on, a second group ofrescuers follows behind the triage officerto bring pa ents to different areas.Treatment area for each priority ofpa ent is the preferred approach in largescale events. In the treatment areasecondary triage of pa ents is performedand that adequate pa ent care is given asresources allow. EMS personnel intreatment area have responsibility toassist and with moving pa ents to thetransporta on area. Na onal DisasterManagement Authori es guidelines onMedical Preparedness on Mass CasualtyEvents iden fied Basic life supporti n c l u d i n g a i r way m a i n tenance,ventilation support , control ofhemorrhage, anti shock treatment andpreparation for transportation as partof basic life support interventions.Under NDMA/ UNFPA new initiative ofMISP, safe child birth is also included.Coordina on of transporta on of MCIvic ms and distribu on of pa ents toappropriate receiving hospitals is a keyon‐scene ac vity of MCI personnel.Ambulances should not drive into thescene of M C I without direc ons.Ac vi es at transporta on area areimportant.Once sufficient emergency medicalpersonnel are assigned to ini al triage,pa ent extrac on, secondary triage, andtreatment areas, subsequent respondingtransport units and personnel reassignedfrom completed tasks can assistin transport.Pa ent extrac on is the act of removingthe remaining vic ms from the affectedareas and delivering them to designatedIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 06

treatment areas. Pa ent extrac on canbegin as soon as resources on sceneallow. Extrac on can commence prior tothe comple on of ini al triage but shallbegin as soon as ini al triage has beencompleted or addi onal personnel inp r o p e r P P E a r e a v a i l a b l e . N o wambulances have GPS tracking systems,permi ng effec ve priori za on anddistribu on of vehicles closest to theincident sites.MCI and disasters may pose two dis nctchallenges as far as EMS staffing. Forlimited disasters there is a need fori m m e d i a t e s u r g e c a p a c i t y w i t hmobiliza on of exis ng staff, which willpermit adequate although short‐termresponse. For large scale or prolongedevents there is a need for preplannedsurge in staffing.The use of pre‐hospital is protocols andonline medical direc on can facilitate andimprove care ini ated in the field.Determining the most appropriate facilityfor a given pa ent's injury is a complexprocess that involves the pa ent's clinicalcondi on, pa ent and family members'preferences, state laws or regula onsthat might affect des na on choices (e.g.manda ng transport to the closesthospital) and hospital and EMS systemcapability and capacity.In training of EMTs, therefore principle ofmass casualty by lectures and groupdiscussions, prac ce in the simula onenvironment or in the real situa on ismandated. Table top MCI exercises are ahelpful way for providers to learn theirrole at an MCI. There should be planningof mass casualty. Logis cs includingcommunica on equipment, facili es,food and water, fuel, ligh ng and medicalequipment for emergency responders isequally important and should be part ofthe planning and preparedness.New technologies, techniques and toolsto improve trauma care also directimpact in addi on to the training,planning and prac ce.When an incident draws to a close, thereshould be a termina on of command.A er the incident, and a er cri que, wecan look back and “post‐plan” as if theincident were something more serious.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 07

MCIs take a physical and emo onal toll ofEMTs. Hence, EMTs should take fulladvantage of stress debriefing a er anevent.Every p re ‐ h o s p i ta l care systemsregardless of its budget, size and loca on,may be required to respond to such MCIsand disasters. Many fatal injuries may beprevented or their severity reduced byadequate pre‐hospital trauma care. it ist h u s p o s s i b l e t o m i n i m i z e t h econsequences of serious injury, includinglong‐term morbidity or mortality bypromptly providing effec ve pre‐hospitalcare by EMTs in MCIs. Guidelines forEssen al Trauma Care, World HealthOrganiza on also emphasizes planning ofemergency medical services, pre‐hospitaltriage, transfer criteria and transferarrangements between hospitals toimprove trauma care in individualcountries.N M D A g u i d e l i n e s o n M e d i c a lPreparedness in Mass Casualty amplyrecognizes the need for trainedemergency medical response teams;promo on of concept of triage; basic lifes u p p o r t a n d p r e p a r a o n f o rtransporta on; mock drills twice a yearand integrated ambulance network(IAN).Thus, the most effec ve func on of EMTon site in MCI is to survey the site,es mate the numbers, severity, and typeof causali es, find a suitable staging areafor pa ent care and for ambulances,determine the best way for entry and exitlanes for ambulances, liaise with policeand other relevant authori es alreadypresent and establish a communica online with Emergency Response Center inaddi on to the triage, treatment andtransport.References:1. Fundamentals of Emergency Care,Richard Beebe and Deorah Funk;Delmar‐ Thomas Learning, 2001.2. Mosby, EMT‐ Basic Text Book, Walt A.Stoy and the Center for EmergencyMedicine, Mosby Lifeline.3. Text Book of Emergency Medicine,Vol.2, Wolters Kluwer Health,(India),2012. h p://en.wikipedia.org/wiki/ Mass‐casualty_incidentIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 08

th4. on 11 June, 2013 h p://www.emsconedonline.com/pdfs/EMT‐Mass%20C a s u a l t y % 2 0 I n c i d e n t ‐an%20overview‐Trauma.pdfth5. on 11 June, 20136. EMS, A Prac cal Global Guidebook,PMPH‐USA, Interna onal Federa onfor Emergency Medicine; Judith E.TIn nalli, Peter Cameron and C.James Holliman, 2010.Mock C. Lormand JD,Joshipura M.Peden M, World Health Organiza on,200411. Essen als of Emergency Medicine,Editor in Chief Richard V. Aghababian,Jones and Bartle , 200612. Na onal Disaster ManagementA u t h o r i t y o f I n d i a , M e d i c a lPreparedness and Mass CasualtyIncident, 2007.7. Brady, Interna onal Trauma LifeS u p p o r t fo r P re h o s p i ta l C a rethProviders, Johm Emory Campbell 6Edi on, 2008.13. h p : / / w w w. s a f e b i r t h e v e nhere.org/8. Na onal Guidelines for Pre‐hospitalTrauma Care and Management ofTrauma Vic ms, Report 2011,d e v e l o p e d u n d e r W H O a n dGovernment of India, BienniumProgram.9. Nancy Caroline's Emergency Care inthe Streets, American Academy ofOrthopedic Surgeons, Jones andthBartle publishers, 6 edi on,2008.10. Guidelines for essen al trauma care,,Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 09

OriginalArticleApplication of NSSK training Skills (Basic Resuscitation) at the Workplace by HealthPersonnel in Andhra Pradesh1 2 2P. Satya Sekhar , V. Jayasankaraiah and K. Pitchi ReddyAuthor affiliations1. Professor in Management, IIHFW, Hyderabad2. Medical consultants, IIHFW, HyderabadABSTRACTThe retrospective study assessed the applicability of basic resuscitation skills acquired inthe Navjaat Sishu Suraksha Karyakram(NSSK) training by health personnel and skillutilization in day‐to‐day work place situation. The findings showed that out of 338newborns with asphyxia related complications, one‐fourth started breathing immediatelyafter change of wet cloth by a dry cloth, two‐thirds (62‐65%) responded to suction andstimulation in the first thirty seconds after birth and 11% required Ambu bag ventilation.Availability of dry washed sheets/towels, mucous sucker and warmer/200 watt bulb atevery delivery point and early initiation of bag and mask within golden one minute withprompt recognition, quick reaction and effective ventilation by health personnel areessential for an immediate reduction of early neonatal deaths in the state.During the last five decades, emphasishas been placed on reducing childmortality largely through immunization,oral rehydration and control of acuterespiratory infections. Consequently,deaths among children over one month ofage have sharply declined. Duringtriennium ending from 2003‐05 to 2009‐11, infant mortality rate in AndhraPradesh declined from 58.3 deaths per1000 live births to 46. The rich benefits ofhigher antenatal care visits, institutionaldeliveries and deployment of medicaland paramedical staff including ASHA atvillage level under the National RuralHealth Mission (NRHM) did not reflect aproportionate decline of early neo‐natalmortality rate (4 points decline from 37.3Address for correspondence:Dr. P. Satya SekharProfessor in Management, Indian Institute of Health and Family Welfare, Hyderabad‐38Email: psekhar9@gmail.comIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 10

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra Pradeshper 1000 births in 2003‐05 to 33.5 in2009‐11 (SRS, 2011). According to NFHS‐2 (1998‐99), children of delivered womenwho received all three types of care (antenatalcare, safe delivery and high standardnewborn care) had a lower risk ofneonatal mortality (14.3 deaths per 1000)than those with only one or two types ofcare (49 deaths per 1000). Bang et.al.(2005) reported asphyxia‐specificmortality rate (ASMR) to be around 10.5per 1000 live births in rural Gadchiroliarea. Further resuscitation of ana s p h y x i a t e d b a b y, t h e n s t u d ydemonstrated bag and mask as moreeffective intervention as compared totube and mask or mouth‐to‐mouthbreathing. The major causes of neo‐nataldeaths in the state (Mahabubnagardistrict) were sepsis (34%), asphyxia(24%), pre‐maturity (20%) and congenitalanomalies (11%), respectively (IIHFW,2004).BACKGROUNDSystematic training in resuscitation of thenew born is the cornerstone of modernneonatology. The American Academy ofPediatrics (AAP) and American HeartAssociation (AHA) developed NeonatalResuscitation Program (NRP) in 1987 andprovided resuscitation training todelivery assistants. NRP is a standardizedapproach/protocol resuscitation widelyused in developed countries and isapplied to a limited extent in developingcountries, where it has greater potential.The NRP registered an impact andbrought down neonatal mortality inTurkey from 41 to 29 per 1000 live birthsbetween 1998 and 2003. It was popularin over a hundred countries and theprogram was translated into 25 differentlanguages (Panna Chowdary, 2009). InIndia, NRP training program was startedas a certificate course under the aegis ofthe National Neonatal Forum (NNF) andsubsequently added to the curricula ofmedical and nursing students (Deorari et.al, 2000).The MOHFW, GOI in collaboration withIndian Academy of Pediatrics (IAP) andNational Institute of Health and FamilyWelfare (NIHFW), New Delhi initiatedthe NRP training program in the countryu n d e r N a v a j a a t S i s h u S u r a k s h aKaryakram (NSSK) also popularly knownas a 'First Golden Minute Program' during2009. The objective of NSSK training is toIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 11

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra Pradeshtrain health personnel on basic newborncare and ensure availability of newbornresuscitation at every delivery point in thecountry. In Andhra Pradesh, the NSSKtraining was initiated jointly by the IIHFWand Indian Academy of Pediatrics (IAP),AP Chapter under the auspices ofCommissionerate of Health and FamilyWelfare, GOAP and rolled out in districtsby early 2011.The workshop methodology includes prewritten and pre performance evaluationtests, class room lectures and commondemonstrations followed by small groupdiscussion in the form of modularreading, reply demonstrations onmanikins and individual practice. At theend of the sessions, post‐training test,inclusive of written evaluation andperformance evaluation (Mega Code),was conducted as per NSSK guidelines.A semi‐structured questionnaire was e‐mailed to 600 participants whocompleted NSSK training. The e‐mailsurvey yielded a response rate of 27% i.e.about 162 medical officers and staffn u rs e s r e s p o n d e d d u r i n g J u n e ‐September 2012. Nine out of tenrespondents recalled all six topics viz.,warmer/200 watt bulb, stimulationsteps, hand washing, resuscitation ofnewborn baby, thermal protection,feeding of normal and LBW babies andthree steps of proper functioning of bagand mask, that were covered in thet r a i n i n g . S t e p s o f w a r m ‐ c h a i nmanagement in labour room and postnatalward require re‐emphasis in futuretraining courses. Nine out of ten (94%)trainees were reportedly confident inadministrating the bag and maskindependently at the delivery point(Satya Sekhar et. al, 2012).After completing more than 200 batchesof NSSK workshops across the districts inthe state, the IIHFW conducted anevaluation study to assess the retentionlevels of trainees on basic newbornresuscitation steps and utilisation ofacquired NSSK skills at their work place.Several reviews with delivery point staffand personal interactions revealed thatneonatal resuscitation procedure ofsuction, stimulation and bag and maskhave potentially saved many newbornlives in health facilities. Lack ofdocumentation of information exists atIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 12

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra Pradesheach delivery point, to guide programplanners as to how many lives could haveb e e n s a v e d d u e t o i m m e d i a t eassessment, stimulation and bag andmask application as demonstrated inN S S K w o r k s h o p . T h e p r e s e n tretrospective study will fill the gap byanalysing interventions of basic newbornr e s u s c i t a t i o n b y N S S K t r a i n e dparticipants in delivery points across thestate.OBJECTIVETo assess the basic resuscitation stepsimplementation in labour room/deliverypoints by NSSK trained health personnel(medical officers and staff nurses).METHODOLOGYA model questionnaire developed andshared by Dr. Panna Chowdary wasmodified in consultation with a team ofexperts in Hyderabad on the basis ofNSSK training manual. The modifiedquestionnaire has been field tested inWest Godavari and Nellore districthospitals and later fine‐tuned. The firstpart of the questionnaire includes healthfacility delivery statistics, availability andworking /usable status of items availablein labour room preceding three monthsprior to the date of survey. The secondpart of the questionnaire includesi nfo r m ation o n re s u s c i tation o fasphyxiated deliveries with details ofmother's name, date of delivery andother delivery characteristics. The studyis based on health facilities, labour roomrecord, and reported asphyxia baseddeliveries attended by doctors and staffnurses who underwent the basicresuscitation NSSK training program.A sample of 338 mother‐newbornrecords with asphyxia was collected fromthe Parturition (delivery) Register from22 health facilities as detailed inappendix‐1). All data, mother‐newbornrecords and treatment particulars wereentered in to the computer and analyzedby SPSS package.RESULTSBetween June 2011 and March 2012period, about 8775 deliveries wereconducted in 22 hospitals, out of which508 neonates reported asphyxia relatedproblems (Table‐1). The percentage ofasphyxia problems to total deliveries isfound to be higher in district /sub‐districtIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 13

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra Pradeshhospitals (6.38%) as compared to basiclevel (5.19%). As a result of simplecalculations done on the basis of neonatalmortality rate (NNMR) of 34 per 1000 livebirths (SRS 2010), the Asphyxia relatedmortality rate (ASMR) per 1000 live birthsworked out to about 6.6 per 1000 livebirths in Andhra Pradesh which is closerto the current study figure.Table‐1 Percent of newborn reportedwith asphyxia to total deliveries duringJune 2011 to March 2012S.No.1.2.Type ofhealthfacilityArea Hosp/Sub‐distHospital (13)PHC (24x7)/ PHC (9)Total (22)Number ofnewbornwho wereresuscitated283225508Totaldeliveries443743388775Percent ofnewbornwho reportedasphyxia6.385.195.79Every birth attendant required newbornresuscitation skills like anticipation,preparation, timely recognition and quickand correct action along with necessarye q u i p m e nt. A p p e n d i x‐ 2 p rovidesinformation on facility‐wise equipmentavailability and working status. The labourroom equipments in the selected healthfacilities such as warmers, dry washedtowels, shoulder rolls, Deelys mucussucker, self inflating Ambu bag and wallmounted clock with second's hand are inadequatein number and some of themare found to be in non‐functional state.Thirteen percent of newborns are of lowbirth weight (below 1800 grams) andsuffer with major neonatal problems.Babies weighing more than 1800 gramsare generally stable at birth and can be puton Kangaroo mother care (KMC) andinitiated into breast feeding. Sixty‐threepercent of newborns in the healthfacilities were breastfed within one hourof birth. Among normal babies (>=2500grams), about four‐fifths (82%) ofnewborns are cord‐clamped within 1‐3minutes of duration. More than half (52%)newborns in 24x7 PHCs (basic level) wereapplied sterile gauze / ointment to cordstump against 2% in district/sub‐districthospitals (Chi‐square=52.33, p=.000). Halfof newborns started breathing between1‐3 minutes and 9.9% breathed after 3‐5minutes of birth. The important activitiesadopted in the health facility immediatelyafter child births are: a) placing the babyon mother's abdomen (98.4%); b)immediately change of wet cloth afterbirth (100%); c) use of separate sterilecotton wipes for cleaning eyes (94%); d)covering the baby with dry cloth over thehead and wrapping (94%) and e) baby putIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 14

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra Pradeshto Kangaroo mother care (67%). Specialemphasis on skin‐to‐skin care, Kangaroomother care to protect newborn fromhypothermia and early initiation of breastfeeding are required in all future trainingprograms.According to NFHS‐3 (2005‐6), the neonatalmortality rate (NNMR) in the statewas 40.3 per 1000 live births during 2000‐05. The present survey also indicatesNNMR as 38 per 1000 live births. Twentysevenpercent (93/338) newborn reportedno meconium was stained after deliveryand baby was dried immediately. In otherwords, changing wet cloth by a dry clothimmediately after delivery provided basicstimulation for 27% in mild asphyxiatednewborns.Four out of five (79%) newborns wereadministered suction first in mouthfollowed by nose. About 80‐85 percent ofcases during stimulation adoptedscientific methods like flicking on the solesof the feet and gently rubbing thenewborn's back. Age old practices likeslapping the back, squeezing the rib cageand shacking were reported on a marginalscale (3‐6%) which appears to bevanishing. This indicates the positiveimpact of NSSK training.DISCUSSIONThe survey results indicate that 27%newborns started breathing by changingwet cloth to a dry cloth immediately afterbirth and remaining 73% requiredresuscitation of suction, stimulation andbag and mask ventilation. Out of them,about 83% of resuscitated newborn, aftersuction and stimulation started breathing;i.e., out of 204 newborns, 194 survivedand 10 babies died after first half minuteof initial steps of resuscitation. The NSSKprotocol suggests initiating bag and maskventilation within 'golden one minute'after child birth. However, study findingsindicate bag and mask were appliedbetween 1‐3 minutes (34%) and between3‐5 minutes (3.8%) after birth as againstthe golden one minute norm of NSSK( Ta b l e ‐ 2 ) . T h e d e l a y e d / f a i l e dresuscitation of bag and mask may beattributed to lack of prompt recognition ofproblem (breathing and chest rise) / notreacting quickly / not ventilatingeffectively. Supportive supervision mayhelp to minimize such deaths.The Ambu bag resuscitation wasadministered on 39 babies, out of whom36 survived and 3 died. Thus NSSKtraining / basic resuscitation approach hassaved 36 out of 242 newborns. In otherIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 15

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra Pradeshwords, there would have been 16%(39/242) of neonatal deaths in healthfacilities and due to application of bag andmask approach; it would be possible toreduce neonatal deaths to 1.2% (3/242).The survey findings indicate that basicresuscitation skills (NSSK training) averted14.8% of neonatal deaths at the deliverypoints.Thus with a neonatal mortality rate of 36per 1000 births (SRS 2010) in rural AndhraPradesh, similar decline of 15% inneonatal deaths will yield a substantialdecline of 4‐5 points making the NRHMgoal of an IMR of below 30 easilyachievable by 2017. To convert it intoreality, there is a need to fulfill someessential and important requirements atevery delivery points. They are:1. About 60‐80% of deliveries conductedin APVVP and specialized hospitals ascompared to round the clock PHCs in thestate. The secondary and tertiary levelh o s p i t a l s ( A P V V P a n d t e a c h i n ginstitutions) are not proactive in making allservice providers (medical officers /staffnurses /ANMs /maternity assistants) toundergo training under NSSK which hadmore impact in the survival of newborns.Ensure that all health personnel atdelivery point are trained in NSSK basicresuscitation methods.2. Special emphasis needs to be placedon orienting high‐focus and tribaldistrict authorities on the importanceof NSSK training and its benefits inreducing neonatal mortality.3. Make all delivery points full‐fledgedwith a newborn corner with radiantwarmer/200 watt bulb, supply ofDeelys mucus sucker in every deliverypoint and Ambu bag used in the NSSKtraining.4. Abundant supply of dry and sterilizedwashed sheets/towels to conductinfection free deliveries. Clean cloth(1meter x 1 meter) can be given to themother at the time of discharge, so asto keep the child warm at home bywrapping in a clean dry cloth oralternatively a newborn warm kit canbe supplied to the new mother.5. F o r e f f e c t i v e d i s t r i c t l e v e limplementation, it is required to a)identify 10‐12 facilitators in eachdistrict and depute for training onrotation basis; b) Enhance leadershipand motivational skills amongf a c i l i t a t o r s ( P e d i a t r i c i a n s ,Gynecologists, doctors interested int ra i n i n g e t c ) ; c ) T i m e ‐ b o u n dcompletion of NSSK training in alldistrict/ sub‐district hospital, areaIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 16

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra Pradeshhospital and CHCs where morenumber of deliveries are conducted.6. Emphasis should be made on earlyinitiation of breast feeding andexclusive breast feeding duringtraining.SUMMARY AND CONCLUSIONSThe Navajaat Sishu Suraksha Karyakram(NSSK), a two day skill based trainingunder the National Rural Health Mission(NRHM) showed a significant impact inpreventing early neo‐natal deaths inAndhra Pradesh. The retrospective studyassessed the application of basicresuscitation skills acquired in NSSKtraining by health personnel and skillutilisation in day‐to‐day work placesituation. Out of 338 newborn withasphyxia related complications, 27%started breathing immediately afterchange of wet cloth by a dry cloth, 62‐65%responded to suction and stimulation inthe first 30 seconds and 11% requiredAmbu bag ventilation. The evaluationconcluded that timely initiation of bag andmask within golden one minute protocolafter birth and adequate availability of drywashed sheets/towels; mucous suckerand warmer/200 watt bulbs at everyd e l i v e r y p o i n t h ave c o n t r i b u t e dsubstantially to a sharp reduction inneonatal deaths in the state. The findingsare based on a small sample andpurposively selected health institutions.An in‐depth study with an appropriatestatistical sampling frame is required togeneralize the findings.Table‐2 Neonatal resuscitation ofasphyxiated newborns in selected healthfacilities in Andhra PradeshS. Particulars TotalNoSample(N=338)1 Newborn birth weight2 Presence of liquor /meconium< = 1499 3.31500‐2499 27.52500 + 69.2stained liquor (%) 72.53 Baby cried after change of wetcloth by dry cloth (%) 27.14 Baby cried after suction andstimulation (%) 60.35 Type of resuscitation applied(in liquor meconium stained)Suction 79.0Stimulation 84.2Ambu bag and mask 76.86 Timing of initiation of bag and mask (%)7 Outcome of new born resuscitation8 Initiation of breast feeding< = 1 minute 61.81‐3 minutes 34.43‐5 minutes 3.8Survived and Referred 86.1Died 13.9within one hour 63.49 Baby put on mother 's chest(skin to skin contact) after stabilization 51.7Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 17

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra PradeshREFERENCES:1. Bang AT., Rani Bang AB., Sanjay B.Baitule., Hanimi M Reddy., Deshmukh,MD. Management of birth asphyxia inhome deliveries in rural Gadchiroli:The effect of two types of birthattendants and of resuscitating withMouth to mouth, Tube‐mask or Bagmask,Journal of Perinatology 2005;882‐891.2. Deorari, AK. Paul VK. Singh M.,V i d y a s a g a r, D . T h e N a t i o n a lMovement of Neonatal Resuscitationin India, J Trop Pediatr 2000; 46:315‐317.3. International Institute of PopulationSciences (IIPS) and ORC Macro. 2000.National Family Health Survey (NFHS‐2), 1998‐99; Andhra Pradesh:Mumbai: IIPS.4. Ministry of Health and Family Welfare(MOHFW), Navajaat Sishu SurakshaKaryakram, Basic Newborn Care andResuscitation Program: TrainingManual; 2009: Government of India.5. P a n n a C h o w d a r y . N e o n a t a lResuscitation Program: First GoldenMinute, Indian Pediatr 2000; 46:7‐9.4. Ramana Rao, GV. Shyamalamba Ch.,Rao, C H V S. Baseline survey ofneonatal mortality reduction project:Narayanpet Division; MahabubnagarDistrict: Andhra Pradesh: (Mimeo);2004: Indian Institute of Health andFamily Welfare: Hyderabad.5. Satya Sekhar, P., Jayasankaraiah, V.,Pitchi Reddy, K. A Post‐training impactassessment of Navajaat SishuSuraksha Karyakram (NSSK) Trainingprogram with focus on skill‐basednewborn care in Andhra Pradesh:Mimeo: 2012: Indian Institute ofH e a l t h a n d F a m i l y W e l f a r e :Hyderabad.6. [The authors are very thankful to DrPanna Chowdary for sharing the basicquestionnaire on resuscitation andMr. Lokesh Kumar, D.C, IAS, MissionDirector, NRHM and Director, IIHFW,Dr. P. Rajendra Prasad, Joint Director(Trainings), Commissionerate ofHealth and Family Welfare, GoAP forencouragement and suggestions. Weare indebted to Dr. N.V. Rajeswari andDr. Ravi Kiran Sarma for comments onearlier draft]Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 18

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra PradeshAppendix‐1: Newborn cases resuscitatedby type of health facility and by districtS.NoDistrictDisthospitalSubdist/CHCPHCPHC(24x7)TotalNo. of resuscitatedbaby case studiesincluded1 Visakhapatnam 0 1 1 2 4 1842 Vizianagaram 0 5 1 1 7 233 West Godavari 0 1 1 0 2 64 Nellore 1 0 0 2 3 945 Krishna 1 0 0 0 1 76 Mahabubnagar 0 2 0 1 3 97 Nalgonda 0 1 0 0 1 78 Anantapur 1 0 0 0 1 7Total 3 10 3 6 22 338Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 19

Sekhar, et.al: Application of NSSK training Skills at the Workplace by Health Personnel in Andhra PradeshAppendix‐B Items available (in working condition) in the labour room for New born care in health facilitiesWarmerdeviceDrywashedsheetsShoulderrollsDeelysmucussuckerRubbermucussuckerSelfinflatingAmbubagMask‐sizezeroMask‐sizeoneWallclock withsecondshandWallmountedthermometerOxygensupplySterilecottonswabsBaby capS.NoItems available in the healthfacility1 2 3 4 5 6 7 8 9 10 11 12 13 14 151 MCH Hospital Nellore 3 3 3 2 2 2 2 2 3 3 1 1 32 CHC, Atmakur, Mahabubnagar 1 1 1 1 2 1 1 1 1 3 2 1 13PHC(24x7), Lothugadda,Visakhapatnam N N 3 N 3 3 3 3 2 N N 2 N4 PHC, Butchiyapeta, Visakahpatnam N 3 3 3 1 2 2 2 1 N N 1 25 PHC Madhuravada, Visakhapatnam 1 1 1 1 1 1 1 1 1 3 3 1 16 CHC, Makthal, Mahabubnagar 1 N 1 N 1 1 1 1 1 N N 1 N7 PHC, Devarakadra, Mahabubnagar 3 3 3 1 1 1 1 1 1 3 2 1 28 Area Hospital Suryapet, Nalgonda 3 1 1 1 1 1 1 1 1 1 1 1 19 Area Hospital, Tadepalligudem,West Godavari 1 1 1 N 1 1 1 1 N N 1 1 N10 Dist Hospital, Machlipatnam,Krishna N 1 1 1 1 N N N 1 N 1 1 111 CHC, Chipurupalli, Vizianagaram 3 1 3 3 2 1 3 3 1 3 3 1 312 CHC, Badangi, Vizianagaram 1 3 3 3 1 1 1 3 3 3 1 1 313 CHC, Salur, Vizianagaram N 1 1 N 1 1 N 1 1 N N 1 N14 CHC, Nellimarla, Vizianagaram N 1 1 1 1 1 1 1 1 N 1 1 115 PHC, Gurla, Vizianagaram 3 2 2 3 1 2 2 3 3 3 3 1 116 CHC, Bobbili, Vizianagaram 1 1 1 N 1 1 1 1 1 N 1 1 117 PHC(24x7), Muthukur, Nellore 1 1 1 1 1 1 1 1 1 1 1 1 118Area Hospital NarsipatnamVisakhapatnam 1 1 1 N 1 1 1 1 1 N 1 1 1Note: N: Not available; 1: Sufficient quantity available; 2: Adequate quantity / on demand; 3: Insufficient quantityIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 20

OriginalArticleAbility of a trainee EMT to learn how to use Video laryngoscope and accomplish the taskof IntubationSrinivasa Rao J; Raja Narsing Rao HV; Ramana Rao GVABSTRACT:INTRODUCTION:Intubation is considered to be an advanced intervention among the airway managementtechniques. Video assisted intubation is considered to make the task easyMATERIALS AND METHODS:A group of 29 EMT trainees were taken through a didactic session for 30 minutes followedby demonstration and practice. The time at first instance of placement of endotracheal tubeon a manikin using a video assisted intubation device is recorded. The device used isvividtrac – a video intubating device.A left sided one tail student t‐test is used to assess the statistical significance of the findings.RESULTS:25 of the 29 trainees could accomplish the task on the first attempt. The sample mean timeis 12.04 seconds, hypothesized mean is 15 seconds, and the sample standard deviation is4.89. The t‐statistic is ‐3.02906. The critical value from t‐table for 24 as degrees of freedomand 99% CI (p = 0.01) is ‐2.492. The t‐statistic value less than critical value allows us disprovenull hypothesis.Address for Correspondence:Srinivasa Rao J,Consultant EMLCAddress: 2‐4‐1588, Ashok colony, Hanamkonda, Andhra Pradesh, INDIA E‐mail: srinu.j.rao@gmail.comIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 21

Rao, et. al: Ability of a trainee EMT to learn how to use Video laryngoscope and accomplish the task of IntubationCONCLUSION:The technique of intubation can be acquired by trainee Emergency Medical Technicians,and they would be able to accomplish the task of intubation within the time span allowed.However this requires a thorough large scale analytical study before it can be rolled out as aroutine technique to be taught as a part of curriculum and practiced on the ambulance.KEY WORDS:Video Intubation; Intubation by EMT; Intubation by paramedic;INTRODUCTION:Airway management is an important skillthat plays a critical role in the outcomesespecially in patients who have airwaycompromise. It is the skill that has to beh a n d l e d e v e n i n a p r e ‐ h o s p i t a lenvironment. But a deciding factor thatplays a role in the extent to which anassociate can handle depends on the skilllevel. Most often in India, we limit to basicskills such as placement of NPA or OPAand use of BVM in the pre‐hospital setting.It is just not the availability of skilledpeople that is a limiting factor, but thelicense to practice, ability to teach, abilityto learn and availability of manpower, playa role in provision of advanced airwaymanagement and care on the ambulance.The indications for advanced airwaymanagement have been established, buttheir practice in pre‐hospital setting has amixed support. Some studies haveconcluded that the advanced airwaymanagement in the form intubation insevere head injuries in out of hospitalscenario can actually worsen the(1)outcomes . Some studies have concludedthat the evidence for or against suchinterventions needs to be studied( 2 )further . The complications out ofadvanced airway placement on theambulance include misplacement of thetubes, displacement of the tubes, anddelayed transport to definitive care unit.But simplifying the technique usinggadgets that make the task of training andexecution and implementation easy havea profound impact on the practice of such(3)skills and the outcomes as well .At GVK EMRI the Inter‐Facility Transfers(IFT) handling happen between thePrimary and Community Health centers inrural areas to Area Hospitals and tertiaryIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 22

Rao, et. al: Ability of a trainee EMT to learn how to use Video laryngoscope and accomplish the task of Intubationhospitals. The travel time averages over 2hours and average distance over 40kilometers for First Referral Unit (FRU) ;and over 4 hours and distance over 100kilometers for tertiary referral centers.Even the pre‐hospital Emergency Medicaltransport time from the scene to hospitalis over half hour in some instances. Theoutcome does depend on the carere n d e re d o n t h e a m b u l a n c e a n dsometimes it becomes necessary that wedo perform some advanced interventionsfor the airway management.Over the last decade many new gadgetswhich take the advantage of video assistedintubation have come in to the market.They are being used in the emergenciesand operation theaters to alarge extent.There are studies done to know how thesedevices can be of help for paramedics andmedical students. A study by Mr Nasim etal has concluded that paramedicsperformed more favorable when larynx isvisualized with the aid optical devices‐(4)airtraq in this instance . However they areof the opinion this needs to be studiedwhen used on patients. One study byMaharaj etal has stated that “The Airtraqmay constitute a superior device for use bypersonnel infrequently required to(5)perform tracheal intubation.” . Onemore study has concluded that “TheAirtraq appears to be a superior device fornovice personnel to acquire the skills of( 6 )tracheal intubation.” With all theliterature available in support of theoptical aided visualization of larynx thisstudy is planned to check the abilities ofEMT trainees to handle the device andintubate on an airway trainer.This study is to check whether the samedevice be handled by trainee EMT's. Thedevice selected is the Vividtrac videointubating laryngoscope. The device has ahandle and a groove in which theendotrachel tube can be placed. Thecamera at the tip of the handle is used tovisualize the path. The device can beconnected to any computer.MATERIALS AND METHODS:A group of 29 EMT trainees who havefinished their institutional phase and aregoing for Hospital Phase of training wereexplained about what intubation is, thelandmark that we should look for, how theprocedure is done using the device. Ademonstration of the same is done for thegroup as a whole. Next each student iscalled for performing the procedure onIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 23

Rao, et. al: Ability of a trainee EMT to learn how to use Video laryngoscope and accomplish the task of Intubationthe Manikin. The manikin used is Laerdalairway trainer. The procedure isdemonstrated again to the associate. He ismade to perform the procedure and thetime taken to place the tube, seal the cuffand withdraw the device is recorded. Theexact time taken is recorded using a stopwatch. 30 seconds is taken as the cut off todecide whether he is able to perform theprocedure or not. If he takes more than 30seconds it is considered as failed attemptand made him go for the second attempt.All elective intubations need to beaccomplished within 30 seconds afterinitiating the task otherwise the task needto be abandoned before the next trial is(7)given after thorough oxygenation . These3 0 s e c o n d s i n c l u d e i n s e r t i o n o flaryngoscope, suction time, visualizationof vocal cords, picking the tube andinserting it. With a conventionallaryngoscope all these actions occur oneafter the other; but in video assistedlaryngoscopy, insertion of scope and tube,v i s u a l i z a t i o n o f c o r d s o c c u rsimultaneously. Suction is an independententity. The maximum time allowed for(7)suction in an adult is 10‐15 seconds .Visualization of vocal cords cannot beachieved without suction. So from the 30seconds that is allowed for intubationprocedure a 15 seconds time is set asidefor suction and clearing of secretions andfluids from the oral cavity. As we are usinga manikin and there are no secretions, a15 second time that is presumed forsuction is deducted from the 30 secondsand the mean time accepted forintubation is set to 15 seconds.Only those that can succeed in the firstattempt (after only one instance ofpractice) will be included for the study andthose that cannot succeed in the firstattempt will be excluded (those who took>30 seconds in first attempt). As we have a(25)small sample it is decided to go for onetail (left) student t‐test for assessment ofstatistical significance. Null hypothesis isthat EMT takes longer than 15 secondsand alternate hypothesis is that EMTtakes less than or equal to 15 seconds.Table 1Null Hypothesis H 0Alternate Hypothesis H 1Sample mean > 15Sample Mean

Rao, et. al: Ability of a trainee EMT to learn how to use Video laryngoscope and accomplish the task of IntubationFigure 1: Vividtrac video LaryngoscopePicture courtesy Vivid Medical Incthe first attempt. The 4 are excluded fromthe study. The sample mean time is 12.04seconds, hypothesized mean is 15seconds, and the sample standarddeviation is 4.89. The t‐statistic is ‐3.02906. The critical value from t‐table for24 as degrees of freedom and 99% CI (p =0.01) is ‐2.492.Table 2Attempt Time1 First 12.542 First 113 First 12.44 First 14.55 First 15.96 First 7.47 First 16.88 First 12.59 First 7.310 First 16.411 First 9.612 First 6.313 First 19.814 First 4.415 First 7.516 First 2217 First 13.618 Second 12.919 Second 19.620 First 7.1121 Second 4.2322 First 7.1123 First 8.324 First 18.1825 First 4.3326 First 13.727 First 18.728 Second 23.329 First 13.6Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 25

Rao, et. al: Ability of a trainee EMT to learn how to use Video laryngoscope and accomplish the task of IntubationTable 3Hypothesized Mean 15Sample Mean 12.04Sample SD 4.88798T‐statistic ‐3.0291Sample count (n) 25Degree of Freedom 24Critical value from T‐tablefor 24 degrees of freedomand 0.05 as p ‐1.711‐6Normal Distribution‐4 ‐2 0 2 4 6Figure 2a: Normal distributionTable 10.09Mean 12.04; SD 4.89Null Hypothesis H 0 Sample mean > 15Alternate Hypothesis H 1 Sample Mean

Rao, et. al: Ability of a trainee EMT to learn how to use Video laryngoscope and accomplish the task of Intubationinvolved in managing real life situation.However this is a demonstration that theintervention may be practiced andintroduced as a part of curriculum. Thismay act as an alternative to the traditionallaryngoscope aided intubation. A smallsample and study on manikin may not be arepresentative of actual real life scenario.CONCLUSION:Statistical analysis has rejected the nullhypothesis. The null hypothesis for thestudy is that the EMT cannot achieve thetask within 15 seconds using a videolaryngoscope and this hypothesis standsrejected by results. This probably isenough support for the statement thatEMT can acquire the skill of video assistedintubation and accomplish the task ofi n t u b a t i o n w i t h i n a l l o w e d t i m elimits.Video assisted intubation isdefinitely a technique to depend on foruse by Emergency Medical techniciansand can be considered to be included inthe curriculum for Emergency medicalTechnicians.DISCLAIMER:We do not have any contributions or whatso ever from any of the companies orwhoever it is for the conduct of this study.REFERENCES:1. Wang HE, Peitzman AB, Cassidy LD,Adelson PD, Yealy DM. Out‐of‐hospitalendotracheal intubation and outcomeafter traumatic brain injury; Ann EmergMed. 2004 Nov;44(5):439‐50.2. Lecky F, Bryden D, Little R, Tong N,Moulton C; Emergency intubation foracutely ill and injured patients;Cochrane Database Syst Rev. 2008 Apr16;(2):CD001429.3. Williamson K, Ramesh R, Grabinsky A.;Advances in prehospital trauma care;Int J Crit Illn Inj Sci. 2011 Jan;1(1):44‐50.4. Nasim S, Maharaj CH, Butt I, Malik MA,O' Donnell J, Higgins BD, Harte BH,Laffey JG.; Comparison of the Airtraqand Truview laryngoscopes to theMacintosh laryngoscope for use byAdvanced Paramedics in easy andsimulated difficultintubation inmanikins; BMC Emerg Med. 2009 Feb13;9:2.5. Maharaj CH, Ni Chonghaile M, HigginsBD, Harte BH, Laffey JG.; Trachealintubation by inexperienced medicalIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 27

Rao, et. al: Ability of a trainee EMT to learn how to use Video laryngoscope and accomplish the task of Intubationresidents using the Airtraq andMacintosh laryngoscopes‐‐a manikinst u d y ; A m J Emerg M e d . 2 0 0 6Nov;24(7):769‐74.6. Maharaj CH, Costello JF, Higgins BD,Harte BH, Laffey JG.; Learning andperformance of tracheal intubation bynovice personnel: a comparison of theAirtraq and Macintosh laryngoscope;Anaesthesia. 2006 Jul;61(7):671‐7.7. Nancy Caroline, Emergency Care in thestreets,; American Academy ofOrthopedic Surgeons and Jones andthBarlett publisher;6 edition, Section 2,Chapter 11:Airway management andVe n t i l a t i o n – A d v a n c e d a i r w a ymanagement; page 11.49 to 11.109.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 28

OriginalArticleComparing the Usage of Double Endopharyngeal Tubes Versus the Usage of TraditionalNasopharyngeal Tubes in Manikins with Upper Airway Obstruction in Simulated Seizuresin paediatric patients.Kumara Nibhanipudi, Roger Chirugi, Brett J Sweeney, Akash PandeyBACKGROUND:Airway control can be a difficult task during paediatric seizures especially status epilepticus.The aim of this study was to determine the advantage of the usage of double endopharyngealtubes via nasal passages versus traditional nasopharyngeal tubes in manikins with upperairway obstruction during simulated seizure in paediatric patients.HYPOTHESIS:The usage of double endopharyngeal tubes will be as effective as traditional nasopharyngealtubes (NPT) in manikins with airway obstruction during simulated seizure in paediatricpatients.METHODS AND MATERIALS:Two endotracheal tubes were cut to a length equal to the distance between the tragus of theear and the angle of the nose plus one inch. The distal ends rest in the pharynx and proximalends remain outside the nostril away from the external nares. The proximal ends wereconnected to a Bag Valve Mask (BVM) via a T‐connector. This configuration of materials wasreferred to as the Double Endopharyngeal tube (DEP)This is an in‐vitro study using 3 manikins. The mouth of each manikin was closed so that no aircan pass through the mouth simulating airway obstruction due to displacement of the tongueas can occur in patients seizing. The manikins were labeled to simulate different possibleAddress for Correspondence:Kumara Nibhanipudi, MDAssociate Professor of clinical Emergency Medicine,New York Medical College, Valhalla, NY. Email address: Kumarnibh@yahoo.comIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 30

Nibhanipudi, et.al: Comparing the usage of DET Vs TNPT usage in simulated seizures in manikinspositions of the traditional methods of intubation versus the DEP (manikins A‐C). A scoringmethod was designed to assess the effectiveness of the various methods with a maximumscore of 4 correlating with maximum effectiveness.RESULTS:18 volunteers participated in the study. In all the manikins (A, B and C), a score of 4/4 wasachieved. The group C results were compared to Groups A and B. The differences werecompared using Krausal‐Willis tests followed by Willcox two‐sample tests.CONCLUSIONS:The DEP was as efficacious as NPT for managements of upper air way obstructions as itoccurs in seizing patients.KEY‐WORDS:Double Endopharyngeal Tube; Paediatric Seizure; Airway; Nasopharyngeal Intubation;INTRODUCTION:Upper airway obstruction can occur inpatients having a seizure due to posteriordisplacement of the tongue. Similarobstruction of the airway is also known tooccur in angeoneurotic edema andinfectious conditions like croup,epiglottitis and secondary to foreign bodyobstruction. In our study, we want tos t u d y t h e u s a g e o f d o u b l eendopharyngeal tube (DEP) versustraditional nasopharyngeal tubes inmanikins as it occurs during simulatedseizures.Traditionally in patients with upper airwayobstruction, who are unconscious, theoropharyngeal airway is used. In patientswho are semiconscious or almostconscious, the nasopharyngeal tube canbe used. The nasopharyngeal tube islubricated and the passed through onenostril. The distal end rests in the pharynxand the proximal end is located at theexternal orifice. The purpose of thenasopharyngeal tube is to bypass thetongue that is causing obstruction andpreventing adequate ventilation.Ventilation is performed by using a tightfitting face mask covering both nostrilsIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 31

Nibhanipudi, et.al: Comparing the usage of DET Vs TNPT usage in simulated seizures in manikinsand the mouth which is attached to aBVM. Adequate ventilation is dependenton the seal between the face and maskcreated by the provider. Theoretically inpatients who are seizing, it is difficultmaintain this seal due to rapid violenthead movements, even with the usage of anasopharyngeal tube. The DoubleEndopharyngeal tube is away from theface, requiring no seal to be maintained.The BVM is directly connected to the Ttube connector and hence ventilate iseasily performed even in patients who arehaving violent head movements.The next question that may arise is, “Whatis a double endopharyngeal tube?”The Double Endopharyngeal tube wasdesigned by the first author (KUMARANIBHANIPUDI). Two endotracheal tubeswere cut to a length equal to the distancebetween the ear lobe and the nose plusone inch. The distal ends rest in thepharynx and the proximal ends outside ofthe nostril. The proximal ends areconnected to an BVM via T‐connector. Thisconfiguration is referred to as the DoubleEndopharyngeal tube.providers to create an airway in patientswith airway obstruction secondary to as w o l l e n t o n g u e , o r p o s t e r i o rdisplacement of the tongue duringseizures. The goal is also to facilitate theusage of the BVM for ventilation indifficult situations like seizing patientswith violent head movements.MATERIALS AND METHODS:It is an in‐vitro study using 3 manikins. Theusage of each manikin was closed so thatno air can pass through the mouth thussimulating airway obstruction due todisplacements of tongue as it may occur inpaediatric patients seizing.The manikins were labelled:A. Traditional nasopharyngeal tubepassed through one nostril. Seepicture 1.The purpose of the tube is to enablePicture 1. X ray of neck: DEP Tube with no BVM and no face maskIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 32

Nibhanipudi, et.al: Comparing the usage of DET Vs TNPT usage in simulated seizures in manikinsB. Two Traditional nasopharyngealtubes pass through both nostrils.See picture 2Picture 2 :DEP Tube with no BVM and no face maskC. Double endopharyngeal tubespassed through both nostrils. Seepicture 3.regards to the airway.See the x‐rays 1, 2 and 3.A scoring system of 1 to 4 was used toevaluate the movements of the chest wall.Score 1indicates no rise of the chest wallbilaterally. (0cm_Score 2 indicates faint movements of thechest wall.(5cm)For manikins A and B, the volunteers wereasked to ventilate using the BVM with atight fitting face mask covering bothnostrils and the mouth. (See pictures 1&2)cPicture 3 : X ray of neck: DEP Tube with BVM and no face maskAn X ray was taken in these manikins toensure the position of the tubes inFor Manikin C, the volunteers were askedto connect the BVM directly to the T‐connector of the double endopharyngealtube then asked to ventilate. A couple ofvolunteers were shaking the body andhead of the manikin simulating seizureactivity in paediatric patients.An independent observer (an attendingphysician) was assigned to each manikin.They were asked to score the success ofventilation or chest wall movement usingIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 33

Nibhanipudi, et.al: Comparing the usage of DET Vs TNPT usage in simulated seizures in manikinsthe previously described scoring system.RESULTS:Results: 18 volunteers participated in thestudy. In all the manikins (A, B and C), ascore of 4/4 was achieved.The group C results were compared toGroup A and B. The differences werecompared using Krauskal‐Willis testsfollowed by Willcox two‐sample tests.DISCUSSION:Nasopharyngeal airways are uncuffedtubes made of soft rubber or plastic. Theyare used most frequently for intoxicatedor semiconscious patients who cannottolerate an oropharyngeal airway. Anasopharyngeal airway is indicated wheninsertion of an oropharyngeal airway istechnically difficult or impossible becauseof a strong gag reflex, trismus, massivetrauma around the mouth, or wiring of theupper and lower jaw. The propertechnique of inserting a nasopharyngealtube is to lubricate the tube with watersoluble jelly or anaesthetic jelly and gentlyinsert close to the midline along the floorof the nostril. This results in insertion ofthe airway into the posterior pharynxbehind the tongue. (ACLS Providerm a n u a l p a g e 2 3 ) . A m o d i f i e dnasopharyngeal tube has been used toreduce high upper airway obstruction inpatients with Pierre‐Robins Syndromeand other causes (Chang, Harris & O'Neil,11989 and 2000) . A simple nasal splint canbe used to assist the stability ofnasopharyngeal tubes in the Pierre Robin2syndrome (Smith, 1998) . According to the3BMJ, (Matthew et. al., 1984) , a study ofnasopharyngeal tubes in Pierre‐ RobinSyndrome, they have described the usageof a shortened endotracheal tubeshortened to end just above the epiglottisto provide a stable airway, with thesplinters tongue forward. Stillings and4Lines (1976) , describe the usage ofnasopharyngeal tubes as aid to lateralport construction in maintenance of theairway in pharyngeal flap surgery.5According to Ralson & Charters (1994) , acuffed nasopharyngeal tube can be usedin a difficult intubation situation. In thiscase, a cuffed nasopharyngeal was used tomaintain anaesthesia and subsequentlyto act as a landmarks for the passage of afiber optic laryngoscope loaded with atracheal tube. No such studies have beendone on Double Endopharyngeal tubes.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 34

Nibhanipudi, et.al: Comparing the usage of DET Vs TNPT usage in simulated seizures in manikinsCONCLUSION:The usage of double endopharyngealtubes via both nostrils were as effective astraditional nasopharyngeal tubes inmanikins to manage airway obstructiondue to displacement of tongue as it occursin seizing paediatric patients.The DEP is designed with the ability toconnect it directly to the BVM. Hence ithas the distinct physical advantage ofstability and convenience to ventilate byusing BVM without the difficult task ofmaintaining a tight seal as required inother methods. This is especially true insituations where the violent headmovements produced by seizure activitymake creating a tight face/mask sealnearly impossible.LIMITATIONS OF OUR STUDY:1. The use of volunteers to shake thehead and the body of the manikin is tosimulate seizures, may not be a truesubstitution. A future study, usingactual seizing patients may be moretransferable.2. The use of an “independent observer”to score appropriate ventilation issomewhat subjective. A moreobjective would be to measure distalpressures in the lungs of the manikins.However, at this time our manikinscannot perform this measure.REFERENCES:1. A.B.Chang, IB.Masters, G.R.Williams,M.Harris –A modified nasopharyngealtubes to relieveUpper airway obstruction‐ PedsPulmonology, 2000, March:29(4)‐299‐306.2. Smith AG., A simple nasal splint toassist the stability of nasopharyngealtubes in the PierreRobin sequence associated airwayobstruction: technical innovation‐J.Craniomaxillofac. Surg.1998 Dec: 26(6):411‐4.‐3. D.J.Matthew, R, Dinwiddie, P.J.Helms,D. Heaf‐a reply letter to Dr.T.H.Huges‐Davies' review ofHospital Paediatrics by Millner andHull –British Medical Journal 1984,November 298:17‐1383.4. Stallings J O ., Lines J., Use ofnasopharyngeal tubes as aids tolateral port construction andMaintenance of the airway inpharyngeal flap surgery – PlasticReconstr. Surg 1976Sept: 58(3):379‐80.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 35

Nibhanipudi, et.al: Comparing the usage of DET Vs TNPT usage in simulated seizures in manikins5. Ralston S.J., Charters P., ‐Cuffednasopharyngeal tube as 'dedicatedairway' in difficult intubation.‐6. J.Anaesthesia, 1994.Feb:49(2):133‐Picture 6: Two NP Tubes with BVMPicture 4 :DEP Tube with BV and no face maskPicture 7: X ray of neck: Single NP Tube with BVMPicture 5: Xray of neck: Two NP Tubes (X‐Ray of the neck) with BVMPicture 8: Single NP Tube with BVMIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 36

CaseStudyCondition in a neonate with Rare Congenital Anomaly, Tamil Nadu.Sailaja. P, Vimal. M, Jebin.TGVK Emergency Management and Research InstituteABSTRACTThe situation is rarely anticipated and can be a source of great distress for parents, deliveryroom and nursery staff. Often there can be pressure on medical staff to “make it better” andassign a gender to the child arbitrarily in the first few hours after birth.Ambiguous genitalia currently known as disorders of sex development (DSD) in a newborn,due to increased prevalence of consanguineous mating and multiple siblings in the onefamily. The birth of a child with ambiguous genitalia is a challenging and distressing event forthe family and physician and one with life‐long consequences. Most disorders of sexualdifferentiation (DSD) associated with ambiguous genitalia are the result either ofinappropriate virilization of girls or incomplete virilization.Approximately 1 in 4,500 births are complicated by ambiguous genitalia. GVK EMRIintroduced neonatal ambulance, from inception to till date 3 neonates in 3985 neonates.KEY WORDS:Ambiguous genitalia, Hermaphrodite, Sepsis, Neonatal Emergency Technician.INTRODUCTION:“A Sweet new blossom of humanity”The birth of a baby with ambiguousgenitalia can cause great apprehension forthe family as well as for health careproviders. The data on the incidence andprevalence of conditions causingambiguous genitalia and over all disordersof sex development (DSDs) are limited.A m b i g u o u s g e n i t a l i a a re h av i n gcharacteristic of neither a male or female.Hence the designation is intersex orAddress for Correspondence:Ms. Sailaja .PGVK Emergency Management and Research InstituteHealth visitors training institute, Govt. Kasturba Gandhi hospital for women and children, Chennai‐5. Email: sailaja_p@emri.inIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 37

Sailaja, Vimal, Jebin: Emergency Condition in a neonate with Rare Congenital Anomaly, TamilNadu.Oxygen 6 liters were administered throughBVM. Naso gastric tube insertion wasdone. Frequent suctioning was done.Sniffing position was maintained.ONGOING ASSESSMENT:Reviewing after 10minutes, the neonatecondition and vital parameters wereassessed. During transport the vitals wereSkin color: pinkCRT :< 3secCry and movements‐ mildSpO2‐ 43% (with oxygen)Temperature ‐ 98.6FPulse volume‐ weak.HANDOVER DETAILS:Ambulance reached the hospital at11:20am. While handing over the neonateat the newborn emergency ward, the vitalparameters were showing marginalimprovement. The vitals were as follows atthe time of hand over:Skin color: pinkHR‐ 145b/m,SpO2‐ 97% (with oxygen)Cry and movements‐ mildDOWNES score‐ 4/10HOSPITAL OUTCOME:The neonate was received in the newbornemergency ward. After stabilizing theneonate was shifted to the NICU. After48hrs follow up, the condition of theneonate was improved. Then the neonatewas fixed for further investigations todetermine the sex.DISCUSSION:The neonate was suffering from sepsisand ambiguous genitalia. The neonatewas admitted in the district head quartershospital. In this hospital there is noappropriate facility to give care to thenewborn with specialized equipments. Sothe neonate was transferred to thetertiary care hospital where it is wellequipped neonatal care facility.The N E M T followed the standardguidelines of Neonatal care and was incontact with the NERCP till handover. Thec h a l l e n g e o f N E M T w a s t o g i v epsychological and emotional support tothe parents apart from the Prehospitalcare. The neonate was in very criticalcondition. NEMT closely monitored thecondition and supported the newborn.During handover NEMT narrated theentire history as well as pre hospital careprovided to the attending neonatologist,including a neonatal Patient Care Record.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 39

ReviewArticlesNational Ambulance CodeConstructional & Functional Requirements for Road Ambulances April 2013 (Extract)GV Ramana RaoGVK Emergency Management Research Institute HyderabadAn Expert Committee was constituted with approval of the Honorable Union Minster forRoad Transport and Highways (MoRTH), Government of India, to formulate the “NationalAmbulance Code”. The terms of reference of the Committee were as under: “TheCommittee will formulate 'National Ambulance Code' along with detailed specifications forvarious types of ambulances for the country and prepare a draft amendment notification toCentral Motor Vehicle Rules (CMVR) 1989.”The Committee took stock of the existing trends vis‐a‐vis ambulance construction, designand integration to understand the current scenario, limitations of the existing framework,available technology, manufacturer maturity, local conditions, past trends, etc.The Committee is chaired by Superintendant AIIMS, New Delhi. Members in theCommittee are representatives from AIIMS, Army Medical Corps, Automatic ResearchAssociation of India (ARAI) Pune, Union Ministry of Road Transport and Highways,National High Authority of India, Union Ministry of Health and Family Welfare, GVKEmergency Management Research institute, Apollo Hospitals and Society for IndianAutomobile Manufacturers (SIAM).The committee initially drafted the document in line with the global best practices andlocalized the same to suit Indian requirements. The document was then circulated to SIAM.During the deliberations of the committee the vehicle manufacturers (OEM's) agreed toAddress for Correspondence:Dr. G.V. Ramana RaoGVK ‐ Emergency Management and Research Institute Dever Yamzal, Medchal Road, Secunderabad‐5000014.Phone: 040‐23462222, Fax: 040 23462178. Email: ramanarao_gv@emri.inIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 41

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)issue necessary instructions to the buyer of the incompletely built vehicle about theconstructional and functional aspects of the ambulance. Any body builder who is engagedin the activity of building ambulances need to follow the prescriptions of this code fornecessary compliance, verification or certification.A. Scope: This standard specifies theconstruc onal and func onalrequirements of Category M & Lvehicles used for transport and / oremergent care of pa ents (RoadAmbulance).This code does not detail therequirements of training of the staff inthe ambulance which will be theresponsibility of the user in whosen a m e t h e a m b u l a n c e w i l l b eregistered or the operator as the casemaybe. This code doesn't coverMobile Health Units & other suchspecialized mobile medical facili eswhich will not be used to transportpa ents in supine state but will onlyprovide preven ve, emergent orelec ve medical care / diagnos cfacili es inside the vehicle to thepa ents when sta onary.B. Terms and Defini ons:i. Road Ambulance: Road Ambulanceor Ambulance is a specially equippedand ergonomically designed vehiclefor transporta on / emergenttreatment of sick or injured peopleand capable of providing out ofhospital medical care during transit /when sta onary, commensurate withits designated level of care whenappropriately staffed.ii. Emergency Pa ent: Pa ent whothrough sickness, injury or othercircumstances is in immediate orimminent danger to life unlessemergency treatment and / ormonitoring and suitable transport toappropriate medical facili es ormedical treatment are provided.iii. Types of Road Ambulances: RoadAmbulances are designated asfollows based on the level of carethey can provide:a. Type A Road Ambulance: MedicalFirst Responder: Road AmbulanceIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 42

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)designed to provide emergent out ofhospital medical care to pa entswhen sta onary. This vehicle maybeany CMVR approved Category M or Lvehicle suitable for the terrain to beused in but will not have the capabilityto transport pa ents in supine stateor provide them medical care insidethe vehicle.b. Type B Road Ambulance: Pa entTransport Vehicle: Road ambulancedesigned and equipped for thetransport pa ents who are notexpected to become emergencypa ents.the transport & treatment ofemergency pa ents requiringinvasive airway management /intensive monitoring.C. Vehicle Characteris cs :1. General Construc on: The roadambulance shall comply withhomologa on requirements given instandards no fied under CMVR 1989and this Code. Wherever, there isdifference in the homologa onre q u i re m e n t s g i v e n i n o t h e rstandards no fied under CMVR 1989and this code, the requirements ofthis code will be applicable.c. Type C Road Ambulance: Basic LifeSupport Ambulance: A vehicleergonomically designed, suitablyequipped & appropriately staffed forthe transport and treatment ofpa ents requiring non‐invasivea i r w a y m a n a g e m e n t / b a s i cmonitoring.d. Type D Road Ambulance: AdvancedLife Support Ambulance: A vehicleergonomically designed, suitablyequipped & appropriately staffed for2. Performance Requirements:a. Accelera on : A road ambulanceloaded to the permissible grossvehicle weight shall be able toaccelerate from 0 km/h to 70 km/hw i t h i n 4 0 s , w h e n t e s t e d i naccordance with IS:11851‐ 1986.b. Electrical requirements :i. General: Electrical installa ons shallcomply with those clauses of IEC60364‐7‐708 which are applicable toambulances. Note 1: The reference toIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 43

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)ii.IEC 60364‐7‐708 does not apply tothe original electrical equipment,which is already covered by the typeapproval of the base vehicle.Ba ery & Alternator: Ba eries shallbe posi oned to allow maintenancewithout removing the ba ery from itssecuring device. The construc on ofthe ba ery and all connec ons to itshall be such as to prevent anypossibility of an inadvertent shortcircuit. Addi onal ba eries may berequired to power the medicaldevices carried on board and theintended use of the ambulance. Insuch cases, the manufacturer shallensure op mal charging of theaddi onal ba eries without anyimpact on the primary vehicle ba ery.When the engine is idling, electricalstability should be maintainedb e t w e e n e l e c t r i c a l l o a d a n dalternator output. In order to achievethis it may be necessary to fit anelectrical load priori sa on device tothe vehicle. Further each electricalsocket provided in the pa entcompartment should be permanentlylabelled as regards its voltage &amperage.iii. Electrical installa on : 1 In Type C andD road ambulances there shall be arecessed externally mounted powerconnector to enable external powerto be provided for opera ons such asthe following:a) Charging ba ery(ies).b) Opera ng medical devices, wheninstalled.c) Opera ng a stand‐alone pa entcompartment heater, when installed.d) Opera ng an engine pre‐heater,when installed. The connector for220/240 V, shall be a male connectorand not interfere with the electricaland mechanical safety. The wiringand, where applicable conduits, shallwithstand vibra ons. No wiring shallbe located in or pass through conduitintended for medical gas installa on.The wiring shall not be loaded higherthan that stated by the wiremanufacture.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 44

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)c. Vehicle body :1. Fire Safety: All interior materials shallcomply with the flammabilityrequirements specified in IS:15061 ,as no fied under CMV(A)R, 1989though the standard does not coverambulance in the scope.2. Driver's Seat Configura on : Thedriver's seat Shall comply with therequirements of AIS:023 or IS 15546as applicable and no fied underCMVR3. Minimum Loading Capacity : Theminimum loading capacity shall be inaccordance with Type of RoadAmbulance Type A;‐; Type B: 3; TypeC; 3; Type D: 44. Par on Wall : In type C & D roadambulances, a full par on wall or apar on wall with a door or a windows h a l l s e p a r a t e t h e d r i v e r ' scompartment from the pa ent'scompartment. Where a door is fi ed,it shall be secured against opening ifthe road ambulance is in mo on. Oneor two windows with a minimumsepara on of 100 mm shall beprovided in the par on wall made ofm aterial complying w i t h t h erequirements of CMVR. The windowsshall allow direct visual contact withthe driver. The opening area of thewindow shall have a maximum areaof 0,12 m². It shall be secured againstself‐opening and shall have anadjustable blind or other means ofpreven ng the driver being disturbedb y t h e l i g h t o f t h e p a e n t ' scompartment.5 . O p e n i n g s ( D o o r s , W i n d o w s ,Emergency Exits) : The driver seatshall comply with the requirementsof IS 15546 as applicable and no fiedunder CMVR. There shall be aminimum of two openings – one atthe rear (door/tailgate) and one atthe side (door/window) of thepa ent's compartment. All openingsshall have seals to protect against theingress of water. For Type C and TypeD road ambulance, each externaldoor of the pa ent's compartmentshall be fi ed with a security systemwhich enables the following: a) Lockand unlock from inside without use ofa keyIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 45

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)b) Lock and unlock from outside with useof a key c) Unlock from the outsideusing a key when the door is lockedfrom the inside. In the pa ent'scompartment, there shall be aminimum of two external windows.There shall be one on each side or oneon the side and other at the rear. Thewindows shall be posi oned orscreened to ensure pa ent's privacywhen required.6. Stretcher Loading: In type C & Dambulances, the loading angle ofstretcher should be a maximum of 16degrees.d. Pa ent Compartment: In C & D typeof ambulances pa ent compartmentshall be designed and constructed toaccommodate medical devices. Thewidth of the pa ent compartment forType C and Type D Road Ambulance,a er installa on of cabinets, etc shallprovide 40 ± 15 cm clear aislewalkway between the main stretcher/ undercarriage and the base of squadbench /a endant seats, with themain stretcher located in the streetside (non‐centered) posi on. In TypeD Ambulances, the length of thePa ent Compartment shall provide atleast 64 cm and not more than 76 cmof unobstructed space at the head ofthe primary pa ent, when measuredfrom the face of the backrest of theDoctor's/ Paramedic's Seat to theforward edge of the stretcher. In TypeC & D Ambulances, a minimum of 25cm shall be provided from the end ofthe stretcher to rear loading door, topermit clearance for any trac on orlong‐board splints. The ceiling, theinterior side walls and the doors ofthe pa ent's compartment in Type B,C & D Ambulances shall be lined witha material that is non‐permeable andresistant to disinfectant. The edges ofsurfaces shall be designed and/orsealed in such a way that no fluid caninfiltrate. If the floor arrangementdoes not allow fluids to flow away,one or more drain with plugs shall beprovided. Drawers should be securedagainst self‐opening and wherelockers are fi ed with doors thatopen upwards they should be fi edw i t h a p o s i v e h o l d o p e nmechanism. Type C and D roadambulances shall be equipped with aIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 46

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)lockable drugs compartment withsecurity lock. Pa ent and A endantseat dimensions shall be minimum of381 mm X 381 mm per seat. AirCondi oning shall be op onal in allcategories of Road Ambulancesexcept Type D Ambulances. Naturalcolour balance ligh ng shall beprovided. The colour temperature ofthe interior lights should be minimum4000 Degrees Kelvin. In type DAmbulance, there shall be anaddi onal light within the treatmentarea with a minimum of 1650 Lux. Theinterior noise level in the pa entcompartment in Type B, C & DAmbulances shall comply withrequirements of AIS: 020. In case oftype B, C and D ambulances, all doors,windows and hatches shall not allowingress of dust and rain water when inthe fully closed posi on, All items e.g.medical devices, equipment andobjects normally carried on the roadambulance shall be restrained,installed or stowed to prevent themb e c o m i n g a p r o j e c l e w h e ns u b j e c t e d t o a c c e l e r a o n s /decelera ons of 10 g in the forward,rearward, le , right and ver caldirec onse. Medical Devices :I Provision of medical devices: a) thepa ent transport vehicle (type B)shall have basic professionalequipment for first aid and nursingcare b) the basic life supportambulance (type C) shall haveequipment for basic treatment andmonitoring of pa ents with thecurrent methods of pre hospital carec ) t h e a d v a n c e l i f e s u p p o r tambulance (type D) shall haveequipment for advanced treatmentand monitoring of pa ents with thecurrent methods of pre hospitalintensive care.ii. M e d i cal d evices stora ge: A l lequipment required for a setprocedure shall be stowed ins p e c i fi e d l o c a o n . E s s e n a lequipment required for use outsidethe vehicle shall be easily accessiblev i a n o r m a l l y u s e d d o o rs . A l lequipment shall be securely andsafely stowed to prevent damage orinjury whilst the vehicle is in mo on.Indian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 47

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)iii. Requirements for medical devices:General: The device shall be designedfor use in mobile situa ons and infield applica ons. If a medical deviceis designated as "portable", which ism a n d a t o r y fo r u s e i n s i d e a nambulance (except pa ent handlingequipment according to Table 9. itshall be in accordance with IEC60601‐1 and shall a) be possible to becarried by one person b) have its ownbuilt in power supply (where relevant)c) be capable of use outside thevehicle d) be placed preferably alongthe street side wall of the pa entcompartment or along the ceilingensuring the minimum possibledistance to be connected to thepa ent without hindering themovement of personnel around themain stretcher.iv. Fixa on of devices: The device shallbe restrained by means of a fixa onsystem. The fixa on system(s),maintain system(s) or storagesystem(s) shall hold the device tow i t h s t a n d a c c e l e r a o n s o rdecelera ons of 10 g longitudinal(forward, backward), 10 g transverse(le , right) and 10 g ver cal.v. Gas Installa on: All the componentsshould be cer fied as per ISO/TC121/SC6 and ISO‐15001:2003 as"Compa bility of Medical Equipmentwith Oxygen".Source of Supply: T h e s o u r c e o fsupply shall consist of one or more ofthe following, as per the requirementof the source supplies in the differenttypes of road ambulances.a) Gas in Cylinders, e.g. Oxygenb) Any other compressed medical gas asrequired for treatment and therapyof pa entsc) Vacuum System: The ambulancewhenever fi ed with a sta onaryoxygen system shall have all thee s s e n a l c o m p o n e n t s a n daccessories required for the pipedoxygen system which shall include asa minimum:(i) One no. Pressure Regulator for eachof the supply sources (sta onary aswell as portable)(ii) Low pressure, electrically conduc ve,hose approved for medical oxygenIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 48

Rao: National Ambulance Code Constructional & Functional Requirements for Road Ambulances April 2013 (Extract)(iii) Oxygen piping concealed and notexposed to the elements, securelysupported to prevent damage, and bereadily accessible for inspec on andreplacement(iv) Oxygen piped to a self‐sealing duplexoxygen outlet sta on for the primarypa ent with a minimum flow rate of100 LPM at the outlet. The changingfrom one cylinder to the other shouldnot affect the distribu on pressure inany way and this change over shouldoccur as an fully automa c opera on.vi. List of Equipment:Minimum equipment carried by theambulances according to type of A,B,C and D. Supplementary devicesmay be introduced locally. Equipmentshould meet the standards based onthe type of device. Type of equipmentin the ambulances suggested by NACare grouped undera. Pa ent handling equipmentb. Immobiliza on equipmentc. Life support oxygen treatmentequipmentd. Diagnos c equipmentse. Drugsf. Infusion material and equipmentg. Equipment for management of lifethreatening problemsh. Bandaging and nursingi. Personal protec on equipmentj. Rescue and protec on materialk. Communica onvii. Re cogni o n a n d v i s i b i l i t y o fambulance:The Ambulance Conspicuity Code issplit into six sec ons.a. Colorb. Conspicuity Improving Items (C2I)c. Emblemsd. Warning Lightse. Sirensf. Recogni on of personnelREFERENCES:1. https://araiindia.com/hmr/Control/AIS/422201 344800PMDraft_AIS‐125_F_April_2013.pdf2. http://www.siamindia.com/3. https://www.araiindia.com/For complete details of differentparameters in national ambulancecode (NAC) please refer the reference1 citedIndian Emergency Journal / Vol‐VIII / Issue‐I / June 2013 49

Note:

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