NEWSFLASH - New Delhi, Jan. 7, 2010

Indian ambulances modernize - lack organization, training

By: Aaron Hochman-Zimmerman

A voice from the radio snapped the stream of calm conversation in the ambulance.

The driver geared up to push the crew forward through a maze of morning traffic in North Mumbai. Meanwhile in the back, one medic and one medical attendant made preparations to transport an elderly woman on a ventilator. The siren blared, but traffic was tightly packed.

"We are in emergency and we cannot move," said crew chief doctor Saeed Ahmed of the Ziqitza - 1298 ambulance service over the sound of the siren in his GPS-aided ambulance.

After the 35 minute Mumbai road rally, the crew removed their shoes at the ambulance bay of Prince Aly Khan Hospital and walked inside. Ahmed was briefed on the patient while the crew loaded the stretcher.

It would be another 20 minutes before the crew reached the receiving hospital in Mumbai Central.

During the trip, the woman was never out of the care of a doctor. Her heart rate, breathing and pulse oximetry, the blood's oxygen content, was constantly monitored.

Ambulance companies such as Ziqitza - 1298, Topsline - 1252 and the modern private hospitals have led the way for India's emergency services, but they are small and only in metropolitan areas. Ambulances from municipal hospitals are poorly equipped and are often thought of as just a hearse.

Nationwide, calls are still handled by a varied collection of operators with a range of resources.

The whole system is "far from satisfactory," said Pramod Lele, chief executive officer of Mumbai's Hinduja Hospital.

Most crews plainly have a "lack of expertise," Lele said and are no better than a taxi.

Another chronic problem is the lack of centralized control of emergency assets. Currently, a mix of private companies, political parties, religious organizations and the municipal system operate independently with different telephone numbers, services offered and standards of quality.

Who to call?

"There's no centralized, one single number," said doctor Swapnil Khamare of Hinduja's emergency management unit and some calls go unanswered entirely.

"Many people find it doesn't work," Khamare said.

The public even has a low awareness of the emergency system and how to use it. Many say they would need to call the information line to find the number of an ambulance company.

In New Delhi, St. John's Ambulance Brigade, a volunteer service, has been asked to coordinate ambulance activities for Jan. 26, Republic Day, events since 2007.

St. John's commissioner S.C. Goyal hopes that one day centralized control will expand into the rest of the year, but "the work is enormous," he said.

Goyal admitted that the public's lack of awareness to be a problem, mostly for the municipal operators.

"They tried to give their number through TV and media and so many people don't know," he said.

Goyal double-checked the numbers before stating that 1099 and 102 would connect a caller to ambulance dispatch in New Delhi.

Doctor Mohammad Anees, an emergency physician at Mumbai's Prince Aly Khan Hospital was pessimistic about the prospect of unified command.

"Better communication," is needed between a dispatcher and all of the services, he said "it should be [better], but it is not possible."

"Everybody wants to be the best," he said about the competition for business, however, "the best" is often not very good.

"Night is the worst," Anees said.

"There is not much knowledge," on the part of the crews that arrive at his ambulance bay, he said, but he does not blame the crews themselves.

"What can they do?" he asked with just an oxygen bottle and bandages.

To be effective, an ambulance "has to be a small hospital," Hinduja's Khamare said.

Running a small, rolling hospital

"Sustainability is the most important thing," said Amit Alex, spokesman for Ziqitza - 1298, but his company began with the thought of social responsibility.

Ziqitza - 1298 wants to be accessible to all. It responds to every call without question, Alex said.

The business model provides free care for the poor by charging full price to the wealthy. Up to a 50% subsidy, based on need, is offered for a ride to a government hospital.

Even with such discounts in place, people still neglect to call, he said.

"Indians don't call an ambulance, they take public transportation," he said.

Alex said that his company commits itself to maintaining international standards by training crews to the level of its overseas partner, New York Presbyterian-Weill Cornell Medical Center.

The company is growing, but only in major cities as "you need a large number of rich to subsidize the poor," Alex said, adding that the company also sells ad space on the sides of its vehicles.

Ziqitza - 1298 hopes to prove itself viable in India's eigth largest cities within five years, Alex said.

Topsline - 1252 operates with method of delivering high-speed modern medical care plus a full range of emergency services.

"We have a retail model," said doctor Prabhat Jauhari, Topsline's chief executive officer and "there's a big market for it."

One advantage of the subscription service is that emergency responders have instant access to its registered patients' medical histories.

Jauhari demands that his crews arrive on-scene within nine minutes of a call. If the caller is not a member, the company does not guarantee arrival times as it arranges for payments before a unit is dispatched.

In matters of life and death, Jauhari said "we don't argue about money," but like Ziqitza - 1298, over-zealous charity cannot be allowed to sink the business.

As the industry continues to grow, the Topsline - 1252 model does not suit itself to gathering the ambulance services under one agency, Jauhuri said.

Ziqitza - 1298 would welcome a unified dispatch and communication system so long as standards remain high, Alex said.

To improve the industry, it must find properly trained people.

Most ambulance drivers receive little training, but in the organizations where care is improving, trained medical professionals act as ambulance crew chiefs; although they are typically not certified medical doctors.

If a person graduates with a modern medical degree and goes to work in the ambulance setting, "there is no way he can make a lot of money," said Hinduja's Lele.

Indian ambulance services "are coming up," St. John's Goyal said, but not uniformly.

The countryside still suffers the most from a lack of attention, he said.

"State governments are taking the initiative, things are going on," he said, but "it will take time."