An Elusive Ambulance


The government spends billions on social service delivery system but GMCs associated hospitals have one critical care ambulance and SKIMS has none, reports Saima Bhat

As the 434-km-long highway linking Ladakh with Kashmir closed for six months, there was a crisis. A critical patient needed immediate tertiary care treatment and had to be airlifted to SKIMS, in mid-December.

Once the patient reached the Srinagar airport, an ambulance from the hospital had already arrived. As the attendants saw the vehicle, they refused to get the patient into the ambulance. Losing precious time to the delay, they preferred to search better option as they had already spent a huge amount to reach Srinagar airport.

“When we saw the ambulance was like any other vehicle used for transportation, I refused to get in: no doctor, no paramedic, no oxygen or any other facility,” the patient’s attendant said. “How could I have risked the life of my patient when we had spent lakhs for the air ambulance?”

Influential, they finally managed to have the only critical care ambulance of SMHS hospital, Srinagar to ferry the patient to SKIMS.

 Ambulance in Kashmir is a vehicle to carry patients or corpses and in case of extreme volatile situations, doctors and paramedics to the hospitals. This deficit is for decades, doctors say.

One of SKIMS’s most senior drivers said he is waiting for the critical care ambulance since 1985, his when he joined duties. He is about to retire now.

SKIMS insiders said there were efforts, but only to be discarded by the highest seat of governance, the civil secretariat.

“Since 1985, three proposals were signed by the different directors of the hospital, who forwarded the files to the secretariat but they were thrown in the dustbins,” said a source in the hospital.

“The maximum purchase of vehicles can go up to Rs 7 lakhs but a critical care ambulance costs above Rs 20 lakhs.” SKIMS transports patients, nothing more. With a fleet of 22 vehicles, including ten winger ambulances out of which six are functional and rest are rusting due to technical faults, all these vehicles are categorised under Type-B, vehicles for basic transportation lacking any life-saving support.

The drivers regret the official apathy and say they are held responsible for something which they are not aware of.

“If we have to shift a patient with oxygen support for consultation to another hospital, the authorities put the responsibility of oxygen cylinders on drivers. How are we responsible? We are just drivers, with no training to deal with patients who, most of the time, are in critical state,” said a driver.

During nights, only three ambulances are available in the SKIMS, where the mortality rate is comparably higher. “We call these vehicles coffin carriers. Every day we have to fight with the attendants that we can take only two attendants with a corpse,” said another driver.

Winters added to the immobility of most of these “ambulances”. Usually, they need to be pushed to make their ignition work.

Apart from comfortable seats, a senior doctor of SKIMS said the advanced critical care ambulance should have an Ambu bag, a mask, endo-tracheal tube for intubation in case of pulmonary arrest, oxygen, and defibrillators for rescuing cardiac arrests, ventilator, and emergency medicines. Besides, it must have splints for immobilization of fractures, blood transfusion facilities, and ECG machines.

Srinagar’s SMHS hospital is no different. “The white trucks that we have, do not, in any case, qualify to be called ambulances. We had one with basic life support but then that was damaged in 2014 deluge. Recently we got a brand new critical care ambulance in gift and that is the only possession,” admitted said a doctor.

SMHS hospital has seven vans and three Tata 407 and one advanced critical care ambulances. And its associated hospitals, including Bone and Joint, GB Panth, Psychiatric hospital, Chest Diseases hospital and LD hospital, have 25 standard ambulances.

In last budget session, state’s health minister revealed that the state is in dire need of critical care ambulances and well as the ambulance with Basic Life Support (BLS). He revealed that Ministry of Road Transport and Highways, Government of India has provided 136 BLS under 108 (advanced critical care) and 102 (for gynaecological and child care), and 20 critical care ambulances. Other than critical care, these ambulances, he has said will be used for running 102 services in the state. But so far, only eight critical care ambulances have been provided to Kashmir division under National Rural Health Mission (NHM), which have been handed over to the district hospitals.

Riyaz Ahmad Khan, working as AEE in the directorate of health services, said the critical care ambulances each worth Rs 27 lakhs stand placed at district hospitals, though he adds still two of their critical care ambulances are yet to arrive.

But there are no BLS ambulances in Kashmir division. The funds were released in 2015 by the Ministry of Roads and Highways for procurement of BLS ambulances to the directorate of health services, Jammu, the ambulance nodal officer, but they had started procuring standard ambulances instead of BLS. “The order was cancelled by the Directorate of Health Services, Kashmir, in June 2017, saying that Kashmir division already had 600 standard ambulances, without any facilities, which can be used for 102 services,” said a source in the department.

He also said that the directorate had to go undergo tendering process again. “We will be going for retrofitting of old ambulances, which will increase our strength. We will be having 20 critical care ambulances, with all advanced support system with 180 BLS.”

But as per a source in NHM director’s office, funds of Rs five crores, for the procurement of 24 critical care ambulances, were available since 2010. “In 2016 we released Rs 3.17 crores in advance for purchasing these ambulances and we have still Rs 3.17 crores, which is for the procurement of 108 and 102 BLS ambulances.”

The  purchase  of   all  ambulatory services is stuck with the Jammu and Kashmir Medical Supplies Corporation Limited (JKMSCL). Dr Iqbal, general manager JKMSCL, says, “We have given 21 critical care ambulances and only 3 are pending. He feigned ignorance about BLS and asked to talk to the nodal officer and NHM director.

“You can talk to the nodal officer and NHM director who are doing it in collaboration with state motor garages.”

But both of the departments said the purchase is handled by JKMSCL. But he said the order included 125 BLS ambulances, with 60 each for both divisions.

Engineer Khan, who is single-handedly managing 600 ambulances of Directorate of Health Services, says there is worst ambulances management. “It should have been centralised under a separate engineering unit. How can JKMSCL do the purchases of technical things when they are doctors who do not have a requisite expertise?”

Er Khan claims that Jammu and Kashmir is the only state in India where at least four ambulances are working for 50,000 population when as per the guidelines there should be one ambulance for every 50,000 population in peripheral areas. “We have to reorganise this system.”

He suggests there is need to have private-public partnership (PPP) mode for ambulatory services in the state.

A doctor in Pulwama has a different version. “We usually have one doctor and two paramedics on night duty. But in case of emergencies when we have to refer patients, we can’t leave  the  paramedic to accompany the patient. There should be a dedicated trained staff for these ambulances,” The doctor said.

“The NHM ambulances for maternity cases are free but the other ambulances become costlier for patients, costs Rs 700 at least to Srinagar hospital,” another doctor, serving in Islamabad said. “The government should think of it so that it could be made available at  50:50 basis. Or the private companies or philanthropists should come in and provide the  ambulance services like Edhi is working in Pakistan.”

For the year 2017, J&K has recorded 665 deaths till Mid December in the Road Traffic Casualties (RTC). The figure reveals accidents consume more lives than the conflict.

This became the reason that directorate  sought the availability  of critical care and BLS  ambulances  and  Emergency Rooms in the peripheral  district hospitals. This, they said,  helped to  save  the patient by using most 10 critical minutes and later shift him to avail the tertiary care.

All the advanced support ambulances need trained staff as well. In 2011, director health services, Kashmir, Dr Saleem Ur Rehman, in collaboration with ICRC Geneva, started training his staff with BLS (Basic Life support), ERTC (Emergency Room Trauma course), ACLS (Advanced cardiac life support), HAMET (High altitude medical emergency training.

Initially, 20 doctors were trained and now, in 2017, the department has 7000 trained members, including 5000 in department and 2000 locals.

Interestingly, due to well-trained staff, an official of the health department said that the casualties at yearly Amarnath Yatra also decreased. Against 127 deaths in 2012, this year there were only 25 deaths reported during the two-month long pilgrimage.

Experts believe most of the deaths at cave were because of heart attack and fall. “But now we successfully did thrombolysis at Cave, Baltal, and it has become a routine for district level hospitals and a few sub-district hospitals.”

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